Care Ethics and Phenomenology: A Contested Kinship (Ethics of Care) 9789042940796, 9789042940802, 9042940794

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Care Ethics and Phenomenology: a Contested Kinship Frans Vosman and Per Nortvedt (eds.)

VOLUME 9

Care Ethics and Phenomenology: a Contested Kinship

Ethics of Care Editorial Board Prof. dr. Helen Kohlen, Vallendar Prof. dr. Sandra Laugier, Paris I – Sorbonne Prof. dr. Frans Vosman, Utrecht, chief editor Advisory board Prof. dr. Andries Baart, Utrecht Prof. dr. Guillaume le Blanc, Paris Prof. dr. Sophie Bourgault, Ottawa Prof. dr. Fabienne Brugère, Paris Prof. dr. Elisabeth Conradi, Stuttgart Prof. dr. Chris Gastmans, Leuven Prof. dr. Per Nortvedt, Oslo Prof. dr. Annelies van Heijst, Tilburg Prof. dr. Linus Vanlaere, Leuven Prof. dr. Marian Verkerk, Groningen

Cover from a painting by the German Jewish painter Felix Nussbaum (1904-1944). Site of the Museum of his work: http://www.osnabrueck.de/fnh/10508.asp. Nussbaum has—while firmly rooted in the European tradition of modern art— given the atrocities of Nazism a face. We honor his life and work by pointing at his artwork on the covers of this series Ethics of Care. Felix Nussbaum Talea, 1927, WV nr. 43 Oil on canvas, 100 × 60 cm Private collection Foto © Felix-Nussbaum-Haus Osnabrück Permanent loan from the Niedersächsischen Sparkassenstiftung

Ethics of Care Volume 9

Care Ethics and Phenomenology: a Contested Kinship Frans Vosman and Per Nortvedt (eds.)

PEETERS Leuven – Paris – Bristol, CT 2020

A catalogue record for this book is available from the Library of Congress. All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher. ISBN 978-90-429-4079-6 eISBN 978-90-429-4080-2 D/2020/0602/9 © 2020 – Peeters, Bondgenotenlaan 153, B-3000 Leuven

Table of Contents

ACKNOWLEDGEMENTS INTRODUCTION: Care ethics and phenomenology: a contested kinship Per Nortvedt and Frans Vosman

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SECTION I: Care ethics and its relation with phenomenology Being attentive as a researcher. The value of Waldenfels’s phenomenology for my care ethical empirical study of attentiveness in healthcare Klaartje Klaver Care ethical phenomenological research: bodiliness as a central feature Hanneke van der Meide Being professional is also daring to be a human being: Kari Martinsen’s phenomenological approach to care and its relevance for medicine Elin Martinsen Care ethics as relational responsibility. An approach by way of Emmanuel Levinas Linus Vanlaere & Roger Burggraeve Confronting Neoliberal Precarity: The Hyperdialectic of Care Maurice Hamington

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Phenomenology and Care: Reflections on the Foundation of Morality 133 Per Nortvedt

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SECTION II: Phenomenology and care Sovereignty and the Ethics of Pathos Gernot Böhme

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Ethics in a Quandary Gernot Böhme

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Care of the Self and Care of the Other Bernhard Waldenfels

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Care as Encounter in Situations Hermann Schmitz

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REFERENCES

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LIST OF CONTRIBUTORS, WITH KEY PUBLICATIONS

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Acknowledgements The idea for this book came up in the research group Care and Contested Coherence (CEC), a Flemish-Dutch group of care ethicists (2007-2014), as some of the researchers were adopting phenomenological approaches and had serious theoretical problems to deal with. Some of the participants in CEC have contributed to this volume (Klaartje Klaver, Hanneke Van der Meide, Frans Vosman). We want to thank Mr. Donald Goodwin, who on our request has translated all texts presented in Part II of this book from German to English. We thank dr. Brian Heffernan, Brussels, for his highly esteemed work on the Introduction (Per Nortvedt/Frans Vosman). We thank all anonymous referees for giving their valuable critique. All rights for the translation of the texts, originally in German, by prof. Bernhard Waldenfels and prof. Gernot Böhme, insofar they were needed, were granted by their publishing house, the Suhrkamp Verlag, Berlin (text by prof. Böhme), and Campus Verlag, Frankfurt am Main (text by prof. Waldenfels). The text by prof. Hermann Schmitz is written especially for this volume. We thank Ms. Helene Alice Vestad Nortvedt for her valuable work in the editing process and on the chapter by Per Nortvedt. We thank the Felix-Nussbaum-Haus, based at Osnabrück, Germany, for the permission to use a painting by Felix Nussbaum for the cover of this book.

INTRODUCTION

Care ethics and phenomenology: a contested kinship Frans Vosman, Per Nortvedt

The relationship between philosophical phenomenology and the ethics of care is an intriguing one. This book wants to contribute to clarifying this relationship, and does so mainly from the point of view of care ethics. The topic is worth investigating for many reasons. Phenomenology in the strict sense of the term is more than a century old. Phenomenology starts with Edmund Husserl and early on, for instance in Heidegger, contains reflections on care.1 Care ethics, on the other hand, is a fairly young interdisciplinary approach to care practices, which started with Sara Ruddick and Carol Gilligan in the 1980s. The relationship between care ethics and phenomenology is not self-explanatory, and during the first twenty years of care ethics (1982 onwards) few authors paid any attention to it. In the meantime, care ethics has become pluralistic (Engster, 2015, p.  18-19) and has changed “dramatically” (Keller & Feder Kittay, 2017, p. 540). It is only during the last twenty years approximately that the relationship between phenomenology and care ethics has received greater attention (e.g. Hamington; Klaver; van der Meide; Nortvedt; Vanlaere; Visse; Van Nistelrooij; Vosman; Timmerman & Baart). Even now phenomenology has not yet become an issue of primary concern in care ethics. Yet there are good reasons 1 Boff, 2008, drawing on Heidegger. This is not, of course, to disregard the phenomenology of G.W.F.  Hegel and classical authors who have been credited with providing a phenomenology, like Aristotle (Fortenbaugh, 1975; Oele, 2012)

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to explore the relationship; this book is a modest attempt to generate greater attention for it. One reason for investigating the relationship is that care is both a concept (ethical, sociological etc.), a practice, and a phenomenon that has significant bearing upon human existence and that regards the human condition and human experience as being invested with normativity. This is probably one of the reasons why there are quite a few scholars that study care practices from a phenomenological perspective, philosophically and empirically (e.g. Havi Carel, Patricia Benner, Fredrik Sveneaus, Max van Manen, Karin Dahlberg, Linda Finlay, to mention some of the most prominent researchers). The other reason is that, while care ethics is inspired mainly by feminism and moral psychology, it also has strong metaethical presuppositions. In particular, many scholars in care ethics claim to work on the premise of a relational ontology in which interpersonal relationships have intrinsic value, and relationships shape an inescapable part of human existence. More specifically on an ethical level, concepts such as relational autonomy, dependency, vulnerability, and responsibility are central to care ethics, while phenomenology addresses interdependency and embodiment, as well as responsibility and the sources (epistemological and metaphysical) of moral demands. It is on this philosophical and conceptual level that interaction is possible and potentially fruitful. It is important to say that the scope of care ethics is broader than that of phenomenology. Care ethics as an ethical theory is originally rooted in a particular understanding of the psychology of human beings, their relational attachments and interdependencies. Its founding scholar, Carol Gilligan, is a psychologist who came to formulate an ethics of care on the basis of her psychological research of young people (Gilligan, 1982). Care ethics is also influenced by political theory and analytic normative theory, which shapes arguments in favor of partiality, and of global justice (e.g. Held, 2006; Engster, 2007). Care ethics has developed into a political-ethical theory (thanks to the work of scholars such as Selma Sevenhuijsen, 1998; Joan Tronto, 1992; Fiona Robinson, 2015; Sandra Laugier, 2014; Fabienne Brugère, 2019 and Elisabeth Conradi, 2001), freeing itself of a

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romantic, “motherly” approach to care, and substituting this by a clear political take on practices of caring and being cared for. Caring constitutes the very possibility of living together; without caring practices organized community is immediately torn apart. Oddly enough the constitution of the political is still hardly recognized in care ethics as a political theory. Thirdly, care ethics comprises an epistemology of power: whose knowledge is obscured, whose knowledge counts as knowledge? And more in particular, is the knowledge of vulnerable people honored? The firm feminist roots of care ethics are clearly visible here. Phenomenology, on the other hand, also comprises an epistemology, in the sense that phenomenology in its various forms addresses the basis for human understanding of the world and human embodiment in the world, by investigating human experience and how phenomena show up in human experience. Phenomenology also has a metaphysical basis, in particular in the sense that it addresses the essence and possibility of consciousness and the problems connected with that possibility for understanding human subjectivity and the relationship between mind and matter. Phenomenology inquires into this possibility by investigating how consciousness operates (Husserl’s Ideen) and why an understanding of the mental and of subjectivity cannot follow from the physical, i.e. consciousness understood neurobiologically. This latter is often called the hard problem of consciousness or “the explanatory gap” in philosophy of consciousness. The metaphysical substratum of phenomenology concerns the sources of normativity (Levinas). Phenomenological metaphysics pursues the enigmatic ending of Kant’s Metaphysics of Morals which states that, “And thus, while we do not comprehend the practical unconditioned necessity of the moral imperative, we do comprehend its incomprehensibility” (Kant, 1964, p. 127). Phenomenology, and in particular the works of Edmund Husserl, Emmanuel Levinas, Knud Ejler Løgstrup, Hans Jonas, and Maurice Merleau-Ponty, have important normative connotations that are relevant to care ethics. In particular, philosophical phenomenology shows how the sources of moral demands are theorized and regarded as embedded in the human

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encounter and in relationship with other persons. These moral demands are discussed in care ethics as well, but mostly on a more concrete and practical level. This book first of all brings together care ethicists of different scholarly generations and from different countries (Belgium, Norway, USA, the Netherlands) who each explain their turn to a version of phenomenology, and secondly it includes three of today’s prominent German phenomenologists who have reflected on care. This collection will hopefully stimulate further steps towards each other, with care ethics inquiring more deeply into the varieties of phenomenology, and parts of phenomenology looking for connection with care ethics. This book is more an endeavor to boost mutual conversation than to give some pretended final word. The diversity of approaches presented here reflects how stimulating the conversation is right from the beginning, but it also becomes clear that a lot of ground has yet to be covered. To limit ourselves here to care ethics and its relationship to phenomenology, we hope that greater clarity will eventually arise about why care ethics needs phenomenology, what kind of phenomenology might be the best suited for care ethics to explore further, and what critical insights care ethics must advocate. This collection of chapters that address phenomenology and care ethics consists of two parts. Part one is about care ethics and its diverse uses of phenomenology, taken as a philosophical approach and as a “method” in qualitative empirical research of care and welfare. The latter is linked to a growing interest in care ethics on account of its emphasis on perception, perception of what actually shows itself in caring practices. The questions here are: 1. What kind of care ethics is looking for what kind of phenomenology and for what reasons? 2. Which combination (blend) is appropriate, given the critical aims of care ethics and –much earlier– of phenomenology with its critique of Modernity? Both scholars whose main interest is in care ethics and scholars whose initial interest is in qualitative empirical research have contributed to this inquiry, and they include both established authors and young scholars. Their contributions were all originally written for this volume.

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Part two contains contributions by three phenomenologists that look at care and at practices of caring. These texts are partly translations of existing reflections on care that were originally published in German (see “Acknowledgements”). One text, by Hermann Schmitz, was written especially for this volume. It is our hope that these contributions will enable further access by English-speaking scholars to the highly original phenomenological thinking on care of the German philosophers Gernot Böhme, Bernard Waldenfels, and Hermann Schmitz. The central question in this part is: what kind of phenomenology is suitable for reflection on care and caring practices?

Section I: care ethics and its relationship with phenomenology Klaartje Klaver, in her contribution “Being attentive as a researcher. The value of Waldenfels’s phenomenology for my care ethical empirical study of attentiveness in healthcare” (chapter 2), addresses attentiveness as a central notion in ethics and in care ethics in particular, drawing on phenomenology as developed by Bernhard Waldenfels. Her discussion of attentiveness is situated within her experiences as a researcher in a general hospital (on the oncology ward). She includes the perspectives of health care professionals on attentiveness, i.e. nurses and physicians who were initially suspicious of her as a researcher studying attentiveness on “their” ward. In chapter 3, “Care ethical phenomenological research: bodiliness as a central feature”, Hanneke van der Meide writes about phenomenological research and bodiliness, particularly within the context of care ethical empirical research in a general hospital. One of the studies she is involved in consists of research in geriatric care and care for people with Multiple Sclerosis. She claims that little has been written about the implication of embodiment for qualitative research practices, and her aim is to address both the researcher’s and the participant’s bodiliness in caring practices in interrelationship with each other. In “Being professional is also daring to be a human being: Kari Martinsen’s phenomenological approach to care and its relevance for medicine” (chapter 4), Elin Håkonsen Martinsen elaborates on the

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philosophy of care developed by the Norwegian phenomenologist and nurse Kari Martinsen, in particular from a medical point of view. She explores the conception of perceiving and recording in Martinsen’s work. The conceptualization of seeing with a perceiving eye—understood as openness and receptivity—may be combined with the more traditional investigative gaze in the physician’s clinical encounter with the patient and during the diagnostic examination of the patient. According to Håkonsen Martinsen, both ways of seeing the patient are important for quality care, but the receptive gaze is frequently forgotten in physicians’ ordinary clinical practice. In order to establish the importance of the perceiving eye in clinical medicine, Håkonsen Martinsen illustrates her argument with a case from her own medical practice as a physician, describing how she acquired a different perception of the patient and was only then able to care. In chapter 5, the American philosopher Maurice Hamington discusses neoliberalism within the context of Maurice Merleau-Ponty’s phenomenology. He argues that Merleau-Ponty’s phenomenology, the subject of several of Hamington’s previous publications, provides a tool for care ethicists to criticize the individualization of citizens by neoliberalism and its influence in today’s globalized world. He opts for integration between Maurice Merleau-Ponty’s phenomenological ontology and care ethics. Rather than suggesting policy and practice changes, as many care theorists have persuasively proposed, Hamington contends that Merleau-Ponty can offer care theory an ontological path to decolonizing the contemporary mind from neoliberal thinking. The Belgian scholars Linus Vanlaere and Roger Burggraeve, in their contribution “Care ethics as relational responsibility. An approach by way of Emmanuel Levinas” (chapter 6), present a phenomenology of different forms and modes of suffering. They carefully gloss the story of the surgeon Paul Kalanithi who reflects on becoming severely ill. Levinas’s “suffering in the flesh” plays a major role in the philosophical evaluation of suffering. What is so characteristic of  suffering that it becomes an ethical appeal? In the second part, Vanlaere and Burggraeve focus on the ethical implications of this

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phenomenology for the “how”, the “what”, and the “why” of a relational responsibility of care. The Norwegian medical ethicist Per Nortvedt also calls attention to the importance of Levinas in his contribution “Phenomenology and Care—Reflections on the Foundation of Morality” (chapter 7). He firstly elucidates the respective moral ontologies of phenomenology and care ethics and argues that, compared to some phenomenological positions, care ethics provides a rather sparse understanding of the fundamental sources of human morality. He then discusses the relationship between moral ontologies and human character; how these foundational understandings of ethics (grounded in phenomenology and care) is relevant to phenomena within the fields of moral and social psychology. According to Nortvedt, moral demands show up in intuitive and relational experiences. He draws on the work of the American philosopher Lisa Tessman to make his argument about the significant normativity of certain moral intuitions not to harm the other person. In part II, three prominent German phenomenologists reflect on care, each with their own concept of phenomenology. Gernot Böhme, in his two contributions (chapters 9 and 10), “Sovereignty and the Ethics of Pathos”, and “Ethics in a Quandary”, first discusses the notion and concept of sovereignty in relation to the balance of preserving oneself (autonomy) and losing oneself in the sense of suffering for the other (an ethics of pathos). In his second contribution, he addresses suffering as a central category in ethics in light of the Aristotelian distinction between praxis and poièsis. His radical thesis is that ethics can only be restored to a whole when humanity reaches a new conception of itself. In “Care of the Self and Care of the Other” (chapter 11), Bernard Waldenfels discusses the distinction between care of the Self and care of the Other within the context of Heideggerian philosophy, as well as Victor von Weizsäcker’s medical anthropology. In the last section of his contribution, he addresses what he calls “responsive therapy”, which he argues represents a radicalization of care for the other person. Over the decades, Hermann Schmitz developed a Neue Phänomenologie, a New Phenomenology, which is fairly critical of previous

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versions of phenomenology; he has obtained considerable influence on care practitioners due to the bodiliness of his phenomenology. In his contribution, Schmitz reflects on the situational character of all care. His short chapter (chapter 12), entitled “Care as Encounter in Situations”, will encourage readers to further explore his phenomenology of the body and matter. Schmitz embeds the encounter between people who may or may not be caring in the situation of the encounter. He defines a situation as a multiplicity that is kept together holistically, that is, is more or less delimited from outside. He then explores the bodily encounter and language. According to Schmitz, an encounter between two people, one of whom is in need, and one of whom is possibly giving care, only works if the caregiver has a sensitive feeling for situations from which the singular as singular emerges by virtue of language. Even if care frequently appears in this volume as everyday care, care in ordinary life, and as health care, we suggest that many observations are also valid for different kinds of care. As we see it, there is a lot of ground still to be covered from the perspective of care ethics with regard to phenomenology. If this book prompts the exploration of unknown territory, whether it is to acclaim or to critique, we will be grateful.

References: Boff, L. (2008). Essential Care. An Ethics of Human Nature. Waco, Tx: Baylor University Press. Brugère, F. (2019). Care ethics. The Introduction of Care as a Political Category. With a Preface by Joan Tronto. Louvain: Peeters. Conradi, E. (2001). Take Care. Grundlagen einer Ethik der Achtsamkeit. Frankfurt, New York: Campus. Engster, D. (2007). The Heart of Justice. Care ethics and Political Theory. New York: Oxford University Press. Engster, D. & Hamington, M. (Eds.). (2015). Care Ethics and Political Theory. Oxford: Oxford University Press. Fortenbaugh, W. (1975). Aristotle on emotions. London: Duckworth. Gilligan, C. (2003). In a different voice. Psychological Theory and Women’s Development. Cambridge Mass, London: Harvard University Press, Original 1982. Held, V. (2006). The Ethics of care. Personal, Political, and Global. Oxford: Oxford University Press.

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Kant, I. (1964). Groundwork of the Metaphysics of Morals. New York: Harper Torchbooks. Keller, J. & Feder Kittay, E. (2017). Feminist Ethics of Care. The Routledge Companion to Feminist Philosophy (pp. 540-555). London: Routledge. Laugier, S. (2014). Recommencer la philosophie. Stanley Cavell et la philosophie en Amérique, Paris: Vrin. Noddings, N. (1984). Caring: A feminine approach to ethics and moral education. Berkeley: University of California Press. Oele, M. (2012) Passive Dispositions. On the Relationship between πάθος and ἕξις in Aristotle. Ancient Philosophy, 31(2), 351-368. Robinson, F. (2015). Care ethics, political theory, and the future of feminism. In D. Engster, M. Hamington (Eds.), Care Ethics and Political Theory (pp. 293-311). Oxford: Oxford University Press. Sevenhuijsen, S. (1998). Citizenship and the Ethics of Care. Feminist considerations on justice, morality and politics. London, New York: Routledge. Tronto, J.C. (2009). Moral Boundaries. A Political Argument for an Ethic of Care. New York: Routledge. Original 1993. Visse, M. & van Nistelrooij, N. (2018). Me? The invisible call of responsibility and its promise for care ethics: a phenomenological view. Medicine, Health Care, and Philosophy, 1-11. https://doi.org/10.1007/s11019-018-9873-7 Vosman, F., Timmerman, A.B., & Baart, A. (2018). Digging into care practices: the confrontation of care ethics with qualitative empirical and theoretical developments in the Low Countries, 2007–17. International Journal of Care and Caring, 2 (3), 405-423.

SECTION I: Care ethics and its relation with phenomenology

Being attentive as a researcher. The value of Waldenfels’s phenomenology for my care ethical empirical study of attentiveness in healthcare Klaartje Klaver

Introduction Despite its widely acknowledged importance for care, it has hardly been examined what attentiveness looks like in professional healthcare practice, and how it is influenced and reworked by culture and other social realities in particular local contexts. The majority of empirical studies on attentiveness in healthcare consider attentiveness a category of friendly interaction or good communication (Johansson et al., 2002; McQueen, 2000). In these studies, as well as in the prevailing care practices, care is considered as better when given in a pleasant and friendly manner. This implies that attentiveness is seen as an additional aspect of care; an extra, or a bonus (Klaver & Baart, 2011). Contrastingly, from a care ethical perspective attentiveness is regarded a crucial or directing aspect of care. Attentiveness is defined by Tronto (2013) as the quality of individuals to open themselves for the needs of others. The notion of the existence of a need by assuming the position of another person is seen as the first step in care, which should be followed by a responsibility to respond to this need. This implies that attentiveness has a moral or ethical character. Moral or ethical in the sense that attentiveness may be caring in itself. Attentiveness does not only have an instrumental meaning i.e. that it helps to perform care operations well. This comes to the fore when attentiveness is understood as recognition (Conradi, 2003). By

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being attentive to someone, it is shown that you care about them. This way it can be seen as an expressionate act (Van Heijst, 2011). Being attentive to someone rather than to something is explained by, among others, the phenomenologist Buber as what happens when another person has some special relevance to the subject. This does not mean a practical or emotional relevance, in the sense that someone e.g. uses another, or appreciates or pities him, or is fascinated by him; these are relevancies that fail when it comes to moral attentiveness. In moral attention, the relevance between the theme of the attention and the context must be such that the other becomes the theme within the context of the ongoing attentive life of the subject (Arvidson, 2013, 2006). It is as if the person suddenly becomes threedimensional and the context flat. Now it does not matter if the other, for example, has blond hair or black hair or no hair at all. It’s still there, but only marginal. This is what we mean when we say that another person matters to you: “You are directly relevant to me”. This “compassion”—literally “standing together”—is a special principle of relevance for attention. Besides being moral or ethical, attentiveness from a care ethics perspective is also political. It is not separate from social and societal structure. Marie Garrau (2014) approaches the political character of attentiveness in the first instance by means of negation: she speaks in this context of institutionalized indifference. She explains how care is socially devalued and distributed to subordinate social groups, thereby exempting dominant groups from caring activities. The dominant groups can indeed maintain the fiction of their independence and deny their own vulnerability and the importance of caring activities, allowing for the constitution of autonomous subjectivities and maintaining social cohesion. It is this mechanism of systematic transfer that contributes to maintaining relations of domination that Tronto called the indifference of the privileged (2013). By uncovering the effects of this institutionalized indifference, Garrau invites us to recognize attentiveness as a core democratic value. Whereas she describes institutionalized indifference as a vehicle of inequality and domination, she sees attentiveness as a vector of inclusion and adequate response to the

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complexity of human affairs (Garrau, 2014, pp. 67-68). It is inescapable to face the structural context in which care takes place when studying attentiveness. Attentiveness in healthcare may be put under pressure by, for instance, education and professionalism of caregivers (new trainings, protocols, techniques), bureaucracy (registration, production), and economic thought (market forces). The particular ways in which these context factors influence care practices are underinvestigated in care ethics. It seems to me that the ethics of care focus largely on agency through such approaches as phenomenology and hermeneutics, and resultingly, social structures may be erased or seen as epiphenomena of agency. My perspective of care ethics was developed in the Netherlands (first based in Tilburg and later on in Utrecht) in research groups which have always stressed the importance of seeing experiences as contextualized. However, in my view, the particular ways of approaching this in empirical research do still raise many questions. If we want to do justice to this contextualization in qualitative empirical research, we must acknowledge that we as researchers are also “contextualized” ourselves. This means that our context, the world that is familiar to us, influences the research findings. We see what we see by who we are, what we do, what we are up to and what we have experienced before. Phenomenological research requires to “bracket” our own background and objectives and “step back” so that we are able to observe what matters to the people we study. However, what does this mean when we at the same time acknowledge that experiences are determined by context? This implies that we can only say something about our own experiences in relation to those of others. This means that we can never fully understand other people (Klaver & Baart, 2016) and that certain experiences remain hidden to us, or rather: we hide them. This raises important questions about the position of the researcher in care ethical empirical research. And it also raises questions about our definition of knowledge and what research should bring about. I think we can better understand the meaning and consequences of these questions with the political and responsive phenomenology of Bernhard Waldenfels, as his phenomenology provides starting

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points for meaningfully integrating contextual factors with an analysis of individual action when it comes to being attentive to someone rather than something. It should be kept in mind, however, that the intention of phenomenological philosophers such as Waldenfels was not necessarily the development of an approach for empirical research. In this chapter, I will describe how I have understood Waldenfels’s phenomenology and relate it to studying attentiveness empirically and to the reflection on the role of the researcher. The main aim of this chapter is to contribute to the discussion of empirical research in the context of care ethical research, which in my view is all about being attentive to the experiences of others. I will show in particular that this implies being attentive to the experiences of the researcher himself or herself. These considerations have come up while doing empirical research on an actual care practice, oncology care provided by nurses and physicians in a general hospital. In this sense, it is a way of talking back to both care ethics and phenomenology.

Waldenfels’s phenomenology Waldenfels has characterized his own work as “a further development of the existential-structural phenomenology in Merleau-Ponty’s sense” (1996, p. xvii). At the same time, Waldenfels diverges from Merleau-Ponty and from a number of phenomenological key features. For example, he characterizes his own responsive phenomenology as an open and adaptable form of phenomenology in which intentionality (intending, grasping something as something) is transformed into responsivity (responses to claims). What we respond to is always more than the answer we give under certain circumstances and within certain orders. Rationality can thus be understood as responsive rationality stemming from the creative answers themselves. (Waldenfels, 1996, p. xvii)

From a phenomenological perspective I came to understand attentiveness as a responsivity that interrupts the progress of the natural experience and gives up what we take for granted. Waldenfels argues that this does not lead us to what our experience means, but rather to what our experience is responding to. From this perspective, attentiveness always begins with a bodily experience beyond our

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control. We see, hear, smell, feel or taste something else before we become aware of it. Because our perception of the other does not result from conscious interpretations, we participate in a movement that precedes us when we are attentive to the other. It is the interaction of a “passive” something happening to me (es fällt mir auf) with something “active” I do (ich merke auf) (Waldenfels, 2004, pp. 65-72). Waldenfels argues that the preconscious perceiving of the other’s experiences causes a confusing experience, in which we are connected to as well as cut off from ourselves: our body runs ahead of our self and our consciousness is trailing behind. He argues that there is a lack of space for this confusion in contemporary thinking about human interactions, which usually sees the self as an autonomous, rational and individually acting subject and has little eye for the physical and emotional aspects of our attentiveness and acting. According to Waldenfels, we do not only reasonably and autonomously determine how we will relate to another, but we undergo our body and what it notices and this drives our attentiveness. Therefore, with Levinas (1961-2012) Waldenfels states that the Other should be the starting point of every reflection. Everything that we become aware of when experiencing an other and to which we give meaning is not initially determined by us but by him. More specifically, the physical appearance of the other determines our bodily response to him. Waldenfels therefore does not speak of intersubjectivity like many phenomenologists do but follows Merleau-Ponty’s concept of intercorporeity (Waldenfels, 2007, p. 84). In order to understand and describe the phenomenon of attentiveness in hospital oncology care, I tried to understand what was at stake for the patients I encountered and whether and how this was noticed and responded to by caregivers. With Waldenfels, we would say that it is a double intercorporeity: the how and what of the researcher experiencing caregivers experiencing patients’ experiences, and the researcher experiencing patients’ experiences, starts and occurs between and because of the participants’ bodies. Waldenfels shows that we cannot simply ask participants about their experiences, as this largely escapes their consciousness. In order to gain insight into the experiences of doctors and nurses, I therefore followed their

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rhythms and paths across the hospital, from seeing patients and consulting colleagues to eating lunch and cycling home at the end of the day. By sharing the same place and time and encounters with others, by talking to them and by observing their behaviour, I tried to get closer to their experiences. The split self Waldenfels argues that our preconscious attention for the experiences of another person is especially called for by another’s otherness. This otherness is understood as the uniqueness of someone else and his or her experiences. It refers to someone else as a body, besides myself as a body i.e. before another person appears in front of me, the other appears within me and at my side. According to Waldenfels, the otherness of an other’s experiences is alien to us. The alien is quite different from the other in its origin and the dynamics of the events associated with it. Waldenfels compares and contrasts it to “the other” by beginning with the assertion that the alien is more radical than the other. “Pear” can be the other of “apple,” and “table” the other of “bed.” The one is “simply different from the other” as Waldenfels (2007) says; “it is what the other is not” (p.  7). At the same time, the other represents a kind of counter-point or “double” of the self. Unlike “the other,” the alien does not arise from a mere process of delimitation [of self and other]. It emerges from a process which is realized simultaneously as an inclusion and an exclusion. The alien is not opposed to the same, rather it refers to the Self, to myself or to ourselves, including the “sphere of ownness” from which it escapes. What is alien does not simply appear different, rather it arises from elsewhere. The sphere of alienness is separated from my sphere of ownness by a threshold, as is the case for sleep and wakefulness, health and sickness, age and youth, and no one ever stands on both sides of the threshold at the same time (2007, p. 7). Waldenfels explains that what is alien to us has both an attractive and a repulsive effect on us. In being attentive to the experiences of somebody else, we are confronted with the—in our eyes alien—otherness of his or her experiences. This does not only cause a preconscious

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response, but it also painfully enters our consciousness. We try to understand him/her, and we realize that our interpretations fall short. This double confrontation constantly appears in two opposing movements: approaching us and withdrawing from us. What is “alien” to us can never be our “own” (Waldenfels, 2007, p. 79). Waldenfels argues that it is impossible to get to know another’s experiences completely, because, to be able to do so, we should start in a place that is already physically occupied by the other. Furthermore, we can never understand them without referring implicitly to ourselves, our past experiences, and our social position. At the same time, however, “the existence of the Other depends on my judgement, as if I were a policeman before whom others have to prove their identity” (2007, p.  11). According to Waldenfels, we often try to get a grip on the otherness we experience when we pay attention to the other, since we are meaning-giving beings. However, sooner or later, anyone who undertakes such attempts must acknowledge that they are vain. As a result, the self-evident experience of everything that is so familiar and “own” also becomes unsettled; it makes us realize that something might just as well be different. It helps us see that in addition to a reality that seems self-evident, there are alternative ways to organize the world and live in it. It turns out that we have presuppositions about reality that leave little room for the other’s experiences. During my research, I found out that the attentiveness of doctors and nurses is determined to a large extent by the context in which they have to work with their patients. The hospital, which is focused on curing, on improving the physical body, provides the attentional structures or templates for this. These instrumental attentivenesstemplates are medically reasoned. They follow the logic of diagnose and treat i.e. define what it is that you perceive, explain what it is caused by, and intervene accordingly. These templates are observable everywhere: for example, in the protocols that healthcare providers need to use and their interpretation of those protocols, in the ideas that care professionals have about their tasks, and in unwritten rules on how to behave towards colleagues. These are reflected in the interior of the building, in doctors’ and nurses’ education programs, in

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the things they are assessed and evaluated for, in the primary expectations of patients and in the public standards to which hospitals are compared. Moral attentiveness is therefore under pressure. It is very difficult to work in this hospital (it is hard work to stay in that culture!) and to be “free” from that context and to look at patients in an open, non-pre-structured way at the same time. The fact that all doctors and nurses are in the same boat shows that attentiveness (in this practice) should be understood as a political phenomenon. The reason I discovered this was that my own way of being attentive changed during my stay at the hospital. In a sense, I also went through a socialization process, in order to be able to carry on as a researcher. This is something I have struggled with. To get access to the doctors and nurses I had to work my way into “becoming one of them” in order to “belong there,” and I had to do this “in the ways of the hospital.” In the beginning I was quite naive, I made a thousand mistakes and violated all kinds of unwritten rules. The healthcare professionals, especially the doctors, were extremely critical and defensive or suspicious, even in advance. They rejected me, for example by not granting me access to their intervision meetings or consultation room. All the caregivers I met in the department asked me what I was going to do and whether I came to judge them. “Are you observing if we are patient-friendly?” or “Are you examining the quality of our communication?” Some did not like that I came to study attentiveness. A nurse said: “If they want more attention, then they have to provide money in order to have more staff on the work floor.” And I understood it very well. However, I decided that the only way of continuing my research was to try and gain their trust. I had to make my story about why I wanted to participate in their practice very convincing; I had to prove myself and the relevance of my study. Doubt, naivety and uncertainty were not appreciated. Many times, I felt I was also “made into a thing” and only seen in a functional way. At one morning I arrived in the hospital with some delay. I had been there for more than 2 months then. I would be late for the morning transfer from the doctors, so in my haste I just walked on without first putting on a white coat. Something that I normally always did. The trainer of the Oncology

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department, a very important man in this doctor’s company, who had seen me walk around for weeks, saw me and asked: “Can you introduce yourself?” And the oncologists present chuckled a little: “She’s been here for weeks now!” This made me realize: the trainer of the doctors of the Oncology Department only saw me as I did not wear a white coat. I only caught this attention as I did not wear a white coat. Before that, he had been mistaking me for weeks for one of the doctors. That made me think about the connection between being attentive to colleagues and being attentive to patients. If you are not seen yourself as more than a white coat, then how can you pay attention to patients?

On the other hand, I realised how fast I got used to the hospital. I was very affected by the suffering I faced, but also by how commonplace it was. I quickly joined the usual course of things and thereby in a way contributed to its maintenance.This also meant that I was confronted with patients in a different way. Despite everything I had learned about ethics and being attentive to others, my own way of being attentive to others came under pressure by the need to perform, in order to uphold myself and to gain access to the participants’ practice as a researcher. These rather unpleasant experiences were of crucial importance in order to understand how attentiveness is not a matter of individuals, or attitude or personality, but a matter of sociality and context (Klaver, 2016). It made me realize how hard it is to be attentive to what patients experience while having to work in the oppressive context of a hospital. Many times I was touched by seeing what patients went through. I struggled with my position as a researcher, as I did not respond to these patients in the way I wanted to. By joining caregivers, which was transparent for patients e.g. by wearing a white coat, I thought I often got a glimpse of what patients experienced. However, the only thing I did with it was writing it down in my notebook and using it for my research. I wondered whether observing and “going with the flow” was enough, or if I should have engaged more actively with whom and what I perceived. I felt that, in a way I, or my way of being attentive, contributed to the misunderstanding of or not-seeing the experiences of patients. This section is called “the split self” (Waldenfels, 2007, p.  75), because it refers to ourselves as bodies moving from an inner drive,

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as well as to ourselves as bodies being moved from the outside. We are carried away by both our own actions and goals as well as by those of others. We participate and intervene in a motion which is already on the road and which precedes our initiative (2007, p.  79). The notion of a split self leaves room for extreme forms of confusion and dismemberment. It shows how being attentive to someone makes that what is obvious to us, is called into question by our bodies being affected by others. Our experience of reality appears to be deficient to understand someone else’s experience. This creates unavoidable confusion and chaos. Who are we? Who do we want to be? Relational alienness and the norm According to Waldenfels, the most confusing of the alienness we experience when we are attentive to the experiences of the other, is that it is never clear and precise. Waldenfels argues this is the result of three “relational” features. First of all, the alienness that is perceived when being attentive to the other always has a mutual character: all participants are deeply alien to each other, but by themselves—without each other—they are not alien (Waldenfels, 2007, pp. 67-86). So we are not only alien to each other but also because of each other. This relational alienness is not accounted for by intentionality, the goal-directed sensemaking that is so familiar to phenomenological analysis. Waldenfels argues that everything that appears to us as something, has to be described not simply as something which receives a sense, but as something which provokes a sense without being meaningful itself, yet still as something by which we are touched, affected, stimulated, surprised and to some extent violated. Waldenfels (2007) calls this happening pathos, Widerfahrnis or affect (p. 74). The second relational aspect of the confrontation with the alien is that the otherness always refers back to alienness in ourselves: the inexorable otherness of the other reminds us of something inside us that we usually want to keep for ourselves and hide from the outside world: things we try to forget about, that we cannot get under control. After all, our own body is also partly alien to us: we also experience things ourselves that we cannot understand.

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The third relational characteristic of the confrontation with the alien is that something can always be alien in two ways: we can perceive the alien—depending on the people and the situation—in ourselves or in the other. For example, if we pay attention to someone else in a group of people familiar to us, they may seem alien to us, while we may find ourselves alien in a group with only unknown people (2007, pp. 21-36). Because of these relational aspects, Waldenfels considers the alien as a phenomenon that always appears in a relationship between the Other, ourselves and a (locally, socially, societal, culturally and historically) constructed measure, that represents the norm (“a third”) at that moment and in that situation (2007, pp. 30-35). The alienness we experience when we pay attention to another, can never be reduced to a characteristic of one person. On the contrary, the multitude of arrangements and people make many forms and experiences of alienness possible. This brings me back to my study of attentiveness in hospital oncology, in which the norm as a “third party” so strongly interfered with my response to patients. As I described earlier, the sociality of the people in the hospital encompassed a focus on biology, on the physical aspects of patients. I often struggled with what I observed and asked myself whether I should approach this more actively. Doctors and nurses sometimes discussed their doubts and worries with me, and they appeared to deal with the same struggles: One day I accompanied a resident doctor who had to surprise his patient at the ward as he unexpectedly had to perform a rectal examination. The lady did not complain but afterwards she said that such examinations are terribly painful, even more than giving birth to a child. The doctor only responded with “That bad? Nooo, you’re kidding!”, even though the lady obviously wasn’t. When leaving the ward, the doctor expressed his disbelief to me. Could it really be so bad? The patient’s experience had both caused a preconscious response and had painfully entered the doctor’s consciousness. I understood his disbelief, being aware of my own struggle to relate to what I observed. I kept wondering how it could be that she had so much pain while all the other rectal examinations I had attended did not show the same. Instead of being attentive to this lady who was

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in pain. This made me realize how hard it is to be attentive to what is at stake for a patient.

With the help of Waldenfels, we now better understand what the  embedment of this situation with the doctor and patient in a wider context, implies. The doctor’s attentiveness does not coincide with his character or personality. His avoiding response to the tragedy expressed by the patient is related to a broadly constructed norm. For example, in the context of a hospital, it is apparently normal for a doctor to surprise a patient and suddenly perform a rectal examination. Just as well as it is normal for a researcher, apparently, to observe this all happening without e.g. actively opposing it. Furthermore, in general, a rectal examination is not an extremely painful experience. Besides, most patients do not undergo extremely painful events without uttering clear expressions of pain. However, this lady did have a lot of pain. She expressed this explicitly, but it hardly enterend the doctor’s consciousness (or mine). What I am trying to show is that all these universal points of view, all these norms, jointly constitute the structures of being attentive to patients. At the same time, they are both indispensable for doctors to do their work well and they oppress the doctors’ ability of being attentive to the experiences of this one specific unique patient. The will to know: reflections on order Waldenfels argues that Western thinking about dealing with alienness, in everyday life as well as in science, mainly consists of attempts to overcome or restrict the alienness we experience when we are attentive to another. The two most used strategies for this are, according to Waldenfels, appropriation and romantization. Appropriation is a counter-reaction, which occurs when we feel mainly threatened by the confrontation with another’s experiences. We try to contain the difficult aspects of another’s experiences by interpreting them from our own order, from what is known and familiar to us. In ethnography, this is called ethnocentrism. As a result, we consider the alienness we perceive often to be a problem that needs to be solved by trying to help others overcome it. Waldenfels argues that most of us take

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the strategy of appropriation not only for granted but also to be civilized: often in our view, it is more or less synonymous with getting to know the other. Romantization is the second commonly used strategy that is used to get a grip on another’s experiences. Romanticizing one’s experiences is an overreaction to ordering strategies, which takes place when we feel mainly attracted to the other. Romanticizing consists of focusing on the attractive aspects of the other’s experiences, and idealizing them. In doing so, however, according to Waldenfels, we don’t escape the pitfalls of ethnocentrism because we are still creating our image of the other based on our own ideals, which makes us selfreferential instead of departing from the other. In addition, this rejection of one’s own logic too often depends on the assumption of an unlimited number of (equivalent) logics. Waldenfels considers such radical lifting of logocentric boundaries undesirable, as no classification is found, nor the boundaries between Other and I. This makes romanticizing do just as little justice to the unavoidable difference between the otherness of the other and our ownness as appropriation and order. Seen from Waldenfels’s perspective, the alienness that caregivers experience when they try to be attentive to the experiences of their patients cannot be interpreted without being attentive to the alienness that I, as a researcher, experienced myself through my contact with them. It must be kept in mind that the experiences of others will never be known completely and that studying it may only lead to more insight into the relationship between the observer and the observed1. As a result, the position of a researcher becomes extremely 1 Phenomenology can be characterized by a genuine interest coupled with an attitude of openness and wonder usually referred to in terms of bracketing. Phenomenological researchers have been criticized for this idea of bracketing presuppositions as this would be an impossible task (Van Manen, 2014). According to Waldenfels, every response starts from the Other, from someone or something that appeals to us. According to him, this is not only a given but it arises and is created in experiencing along (Widerfahren) with others. Therefore, a researcher has to make himself visible in the “frame” of the research as an interested, political and subjective actor.

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problematic: after all, scientific research is about increasing knowledge about something that is unknown to date. In their attempts to acquire new knowledge about (being attentive to) the experiences of caregivers and patients, researchers paradoxically enough try to overcome this alienness, by trying to know it, to understand it, and to get a grip on it (Klaver & Baart, 2016). Yet, that very same grip is impossible and there is another kind of knowing that is possible, as shown by phenomenology. Waldenfels shows that the possibility of another mode of discourse does exist and it can occur as soon as we stop speaking (or remain silent) about the alien and start speaking from the alien (Waldenfels, 2011). This discourse is already at work within experience, and it takes place whenever we start from the same appeal or request through which the alien announces itself, by obliging us to respond to it. Therefore, we can only find such a discourse in the register of response. Responding has the capability of not robbing the alien of its sting, as the response itself does not start from a subjective or thematizing act by the own self, but always in delay and as a pathic experience. Only from responding to what we are hit by, can appear what hits as such (Waldenfels, 2011).

Conclusions on being attentive When we look at attentiveness in hospital care from Waldenfels’s perspective, we see that the caregivers’ attentiveness often—without them being aware of it—avoids the experiences of patients. Andries Baart and I (2016) have shown how the different types of attentiveness of caregivers as I discerned them in my study, are all—in a way—forms of avoidance: we described, for example, hurried attentiveness, calculating attentiveness and disciplining attentiveness. These types of being attentive can be task-oriented, aimed at keeping everything as it is, or at ease and simplicity without, for instance, acknowledging that the patient is connected to others (e.g. family members), or at persuading a patient to accept a certain treatment. These types of attentiveness are driven by good intentions, however they are one-sided, narrowly focused, and self-referential, and therefore leave little room for the experiences of patients. What we saw is that caregivers by fostering

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these types of attentiveness, are in fact appropriating the experiences of patients: they are interpreting them from their own order, from what is known and familiar to them. I have also seen a few examples where caregivers were being attentive in a way that romanticized the experiences of patients. For example, I encountered an oncologist who tolerated the behaviour of a patient who had crossed various boundaries. This patient was unreliable, did not keep his promises, and wanted to be treated only on his own terms. The doctor gave him everything he asked for, and only after every appointment could the doctor reflect on this and acknowledge his own repulsion, and thereby state that he consciously chose to endure it (Klaver, 2016, pp. 116-118). These forms of avoidance would be considered by Waldenfels as fundamentally human: each of us is inclined to avoid or ignore the confrontational experience of what is at stake for the other. The tragedy of what others experience is far too big for us. We do not seem to realize that we ourselves are a part of the interaction in which they experience this tragedy. This may be so for different reasons. In my study, it appeared that caregivers often were unable to be attentive to what patients experienced, as this would distract them from their work or because they wanted to keep a distance in order not to become too involved. At other times, caregivers went to the ward just to make an “attention-round”: at those moments it was precisely their goal to be attentive to patients. According to Waldenfels, such individualized approaches, in which attentiveness is pre-structured by the context and logic of the hospital, dismiss the relational aspects of being attentive to others in an unjustifiable way: attentiveness can never be assigned to the characteristics of one person. Attentiveness gets form, content and meaning in the relationships between people. In Waldenfels’s phenomenology, it is crucial that no attempt to be attentive to the other can be fully successful without experiencing unpleasantness and confusion. After all, even if we consciously avoid or ignore someone else’s experiences, we will only do so because something about their experiences has confused us. In this regard, caregivers can only pay attention to patients if they are willing to accept that this will lead to uncomfortable, confusing and painful experiences for themselves.

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They may, for example, be confronted with their powerlessness to do anything about the situation. Waldenfels explains that the willingness to be attentive to what really matters to patients is not easy and that the motivation for it should greatly come from reflexivity. This does not refer to reflection in the modern, cognitive meaning of the word, in which the self is beside things, complementing outer experience with an inner one. Reflexivity refers to a way of accessing the self on the basis of intentionality. It means that I am involved in whatever may appear. It is about the thematization of the correlation between meaning and act and of my living in the world (Waldenfels, 2007, p. 75). It entails many corporeal aspects and refers to a dialogical and a relational act. This is because we are often not aware of our presuppositions and assumptions and we need others to point out our blind spots. In thinking about being attentive to others, we are being thrown back upon ourselves in our relation to the other. Attentiveness in hospital care, Waldenfels would argue, begins with the recognition of an invincible and indivisible distinction between patients and care professionals, a distinction that is highlighted by their bodies, their healthy and sick bodies. Waldenfels emphasizes that the way we are attentive to the other is intertwined with the order in which attention is being paid. The other appears always as something within a local, social, cultural and historical context. As described above, within this relational framework, Waldenfels states that attentiveness, understood as responsivity, consists of certain types of actions and accidents (“being given”) that must be created. These types of experiences do not exist in the world of physical things and processes, nor in the inner world of mental acts. They must be “created” by “determining the undetermined”. In fact, every response, by starting from a non-anticipatable and hence unpredictable request of the alien, is inevitably constituted by a certain amount of unpreparedness and consequently by at least a minimal amount of inventiveness. Instead of intentionality joining “us” to “the world” (as Merleau-Ponty writes, 2002, 1945), Waldenfels describes a responsivity that exists between the “order” on one hand and “the alien” on the other. Correspondingly, his focus is on boundaries, borders and

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limits: on thresholds of attention, on the twilight of order, on the human as a “liminal being,” and significantly, on dia, the “between words,” as contained in the word dialog (Waldenfels, 2011, pp. 8-20). In this respect being attentive can be considered as the very constitutive manifestation of a constantly open and never accomplishable human discourse taking place among us. Paradox of attentiveness In current discussions on healthcare that should be more attentive to patients, the emphasis is on understanding patients by obtaining as much insight into their experiences as possible. Consequently, more and more studies focus on patient-centredness, patients’ experiences, patients’ social worlds, and so on. It is claimed that these kinds of research may help caregivers become more attentive to what is at stake for patients, by taking up an emic point of view. Of course, this is a very good idea. But there is something else, something that is contradictory: it is impossible for caregivers to fully understand patients. With Waldenfels, we understand that when it comes to attentiveness in healthcare, we need to thematize this impossibility as well: the emptiness, the lack of understanding. Conversely, Waldenfels would argue, understanding is being attentive to what comes into existence because of the fostering attentiveness; to what shows itself to the extent that attentiveness seeks the mode of “letting things happen,” while not imposing functionality but respecting otherness. Only in this meaning, we avoid this out of fear of being confronted with a lack of understanding, we fill gaps with our own impressions and we thereby take the position of the other. “Reflecting on our own experience to understand the other is balancing between ‘ego-centrist’ non-understanding and empathic understanding of the other in terms of ourselves” (Van der Geest, 2007, p. 9). As long as we only describe what makes another person different from us, without acknowledging the fact that part of their otherness remains unknown (or: alien) to us, we keep interpreting the other’s experiences on our own terms (as “a second me”), rather than allowing the other’s experiences reach us. Only then the other would “arise as

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co-original of ourselves and to some extent as an earlier version of ourselves” (Waldenfels, 2007, 2004, p. 81).

Discussion on care ethical empirical research Indefiniteness in research Waldenfels’s phenomenology shows us that the experiences of others will always escape us in the end. This constitutes an important criticism of what is usually the focus of phenomenological research, which involves the perception of the phenomena as revealed in their full wealth. This way of approaching phenomena is based on a passage of Edmund Husserl in which he presents phenomenology: “We will consider conscious experiences in the actual richness and completeness in which they occur in their concrete context, the stream of experiences” (Husserl, 1969; Van Manen, 2016, p. 116, my translation). For empirical care ethical research, this implies that we should search for a research approach that also acknowledges the undetermined, or the unknown, of participants’ experiences. This is different from many phenomenological research methods that aim at formulating “essences” of experiences, for example by summarizing or labelling them. Reflection on the position of the researcher This leads to the second implication for care ethical research that may be formulated from Waldenfels’s phenomenology, which asks for a thorough reflection on the role and position of the researcher himself or herself. When we are studying the experiences of others, in phenomenological research often called the study of lived experiences, we have to accept that this will also lead to uncomfortable, confusing and painful experiences. After all, in Waldenfels’s responsivity, when we try to understand the experiences of others, we have to practice self-reflection as we never really get to know the other but have to rely on ourselves in relation to the other. Therefore, care ethical researchers should not only describe their observations, but they should also describe the context in which these take place, i.e. the place and time, their reason for being there, the others involved, the behaviours and inner processes, and the situation they were in

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when the observations took place. This implies that they should not only reflect on why they interpreted the experiences of others as they did, but also that they should be aware that these interpretations are intertwined with the local, social, cultural and historical context. This makes the position of the researcher extremely problematic, because (regular) science is driven by a “will to know”, i.e. a will to objectify and simplify. And one may add: the will to know in order to make an intervention. The implication of the latter is that when trying to reach a full understanding of the intimacy of patients’ perspectives and experiences, one negates the impossibility of such understanding, while still intervening and framing patients’ experiences. Attentive researchers should be reflective on their position and the asymmetrical relations with the participants. What interests are involved in this research? What does this study aim for? Being attentive as a researcher: all the way through For empirical care ethical research, I think it is crucial to be attentive as a researcher from beginning to end. This implies that I resist the idea that researchers can or should be independent or objective. In formulating the research question, in collecting and analyzing the data and in sharing the results, researchers should try to align with what matters to the people involved, and thereby reflect on their own role and position. This implies that our will to know coincides with a responsive form of phenomenology that goes beyond meaning and rules. This involves that researchers should start by persistently resisting the application of existing orders or conceptual frameworks. It begins at the point where something challenges us and calls our own possibilities into question, even before we get involved in striving for knowledge, and in a will to know (Waldenfels, 2007, p. 25). Not every academic question is at stake for the people concerned. Researchers who try to understand what matters to others should then bracket their own perspective and move along with the people concerned. This moving along or “living through” can show them something from the experiences of the people concerned. We acquire our knowledge about the reality that surrounds us by relating to it through our body, our senses, our experiences and our thoughts.

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Therefore, every insight we gain is inextricably linked to the context and the moments when we react to one another, partly as a result of previous experiences. What is crucial here is that researchers recognize that their own experiences are (also) formed by their context, by the world that is familiar to them. In my empirical study of attentiveness in hospital oncology, care ariginated in the problem that moral attentiveness, in the sense of actually seeing and responding to what really matters to people, seems crucial for care and, at the same time, is put under pressure. Attentiveness is drawn by many things in the world outside us that are not concerned with what really matters to people. My study started from the assumption that providing more insight into these dynamics would help to organize healthcare more attentively. Further challenges arise with regard to collecting, analyzing and presenting the data. While (regular) science is focused on simplifying and objectifying in order to provide evidence, care ethical empirical research should try not to simplify care and human affairs beforehand. For the collection of data, it is therefore essential that we cooperate with the participants for a long time, and that we frequently exchange our observations with them. Furthermore, it means that we cannot look at what happens from a distance, or collect our data via interviews, but that we immerse ourselves in the context in which the participants find themselves. Both describing research approaches and theorizing approaches should, besides trying to understand, allow space for ambiguity and indeterminacy. My dissertation provides a grounded model that describes different types of attentiveness and explains their occurrence (Klaver & Baart, 2016a), and it also describes that, at the same time, attentiveness always seems to partly escape the analysis (Klaver & Baart, 2016b). I think that in every care ethical empirical study that has its origins in something or someone that appeals to us, a certain irreducibility and unpredictability is to be included in the analysis. Therefore, the results of such research depend on a complex interplay between time, researcher and research participants, between situations and relationships. Seen in this way, the knowledge acquired in care ethical empirical research is situation-dependent, context-bound,

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personal, relational and changeable in nature. With Waldenfels (2007), I would argue that acquiring knowledge in care ethical empirical research can best be understood as a series of events (pp. 37-52) in which researchers should always be aware of the asymmetrical distribution of time, money, influence, privileges, and capacities that influence every organizational context (Tronto, 2013). Waldenfels’s view of knowing also provides added value for the way we present our results. We must bear in mind that the main goal of presenting findings is to serve as a reliable guide to the reader’s/ listener’s/observer’s own actual or potential experience of the findings. The essential function of whatever presentation is therefore “to provide unmistakable guideposts to the phenomena themselves” (Spiegelberg, 1960, p.  673). However, referring to Waldenfels, we should stress the importance of leaving room for a certain uncontrollability. If we want to present our knowing in a way that resonates with our audience, we have to think of an evocative way of presenting our findings that makes contact with their bodies, their senses, their experiences and thoughts. In my dissertation, I have added “background stories” that describe some of my encounters with others in the hospital. These stories aim at allowing the reader to experience the hospital culture and what it does to our way of being attentive, and they probably provide the most direct insight into what is brought into play when it comes to attentiveness in hospital care. How can we best approach care ethical empirical research? I would not recommend or reject any research method in advance. The research question that comes up in interaction with the people concerned should be guiding. It should provide the type of results that are required in helping to organize care more carefully. However, every approach should be accompanied by a reflection on what it may hide besides what it shows.

References Arvidson, P. (2013). Restructuring attentionality and intentionality. Human Studies 36 (2), 199-216. Arvidson, P. (2006). The sphere of attention. Context and margin. Dordrecht: Springer.

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Conradi, E. (2003). Take care. Grundlagen einder Ethik der Achtsamkeit (Thesis). Frankfurt am Main. Garrau, M. (2014). Care et attention. Paris: Presses Universitaires de France. McQueen, A. (2000). Nurse-patient relationships and partnership in hospital care. Journal of Clinical Nursing 9, 723-731. Johansson, P., Oléni, M., & Friedlund, B. (2002). Patient satisfaction with nursing care in the context of health care: a literature study. Scandinavian Journal of Caring Sciences 16 (4), 337-44. Klaver, K. (2016). Dynamics of attentiveness in care practices at a Dutch oncology ward (Dissertation Tilburg University). Klaver, K. & Baart, A. (2011). Attentiveness in care. Towards a theoretical framework. Nursing Ethics 18 (5), 686-693. Klaver, K. & Baart, A. (2016). Managing socio-institutional enclosure. A grounded theory of caregivers’ attentiveness in hospital oncology care. European journal of oncology nursing 22, 95-102. Klaver, K. & Baart, A. (2016). How can attending physicians be more attentive? On being attentive versus producing attentiveness. Medicine, Healthcare and Philosophy 19 (3), 351–359. Manen, M. van. (2014). Phenomenology of Practice. Walnut Creek, CA: Left Coast Press. Tronto, J. (2013). Caring democracy. Markets, equality, and justice. New York: University Press. Merleau-Ponty, M. (2002; 1945). Phenomenology of Perception. New York: Routledge. Van Heijst, A. (2011). Professional loving care. Leuven: Peeters. Waldenfels, B. (1996). Order in the twilight. Athens, OH: Ohio University Press. Waldenfels, B. (2004). Phänomenologie der Aufmerksamkeit. Frankfurt am Main: Suhrkamp. Waldenfels, B. (2007). The question of the Other. New York: SUNY Press. Waldenfels, B. (2011). Phenomenology of the alien: basic concepts. Evanston, IL: Northwestern University Press.

Care ethical phenomenological research: bodiliness as a central feature Hanneke van der Meide

Introduction Care ethics is an interdisciplinary field of inquiry, which is driven by societal questions. My view of care ethics has been developed in the Netherlands where conceptual and theoretical research go hand in hand with empirical research (Klaver et al., 2014; Leget et al., 2017). Preferably, care ethical research reflects a reciprocating movement between critical conceptual research and empirical research. Phenomenology is part of the “care ethical methodological toolkit” (Leget et al., 2017) and is an oft-used research approach in care ethical studies. Care ethics shares with phenomenology that it developed as an alternative to mainstream thinking, thereby emphasizing the concrete lived reality. From the beginning in the 1980’s, care ethicists have been critical of the very idea of universal ethical principles that should be applied to everyone regardless of the context. An important insight of care ethics is that “morality itself consists in practices, not in theories” (Walker, 2007). For this reason, care ethics takes a bottom up perspective and values the experiences of people in moral reflection (Vosman & Niemeijer, 2017). Although experiences are increasingly being taken seriously in ethics, usually a particular ethical lens comes first. This lens defines—either prior to or during the study—what is ethically relevant (Vosman, 2017). What phenomenology can bring to care ethics is an open attitude in order to

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understand the concern(s) of the other(s), to suspend ethics and not to see too quickly what we already know or what we expect. The phenomenological adage Zurück zu den Sachen selbst can be understood as studying the “affairs” of daily life—that what matters to human beings (Churchill, 2010 in Finlay, 2014). The phenomenological question, “what is it like to experience this phenomenon or event?” compels us to make sure that care ethical theories remain grounded in the actual lives and daily concerns of people. The sense of wonder that is expressed in this question is, I believe, essential for care ethics to hold on to its bottom up perspective. Since its foundation in the early years of the 20th century, phenomenology has developed into a variety of strands of thought with a multitude of angles and foci.1 Although all phenomenology is oriented to the practice of living (Van Manen, 2014, p. 69), with the Utrecht School as an exemplary example, it was not until the early 70’s that phenomenology developed into a qualitative research practice. The psychologist Amadeo Giorgi and his colleagues of the Duquesne University developed the descriptive phenomenological method to avoid the reductionist tendency in psychological research. Ever since, a multitude of research approaches emerged that have been inspired by phenomenology (Finlay, 2009). The term phenomenology is nowadays used for a wide range of qualitative studies and some authors question whether justice is done to phenomenology as a philosophical approach (Finlay, 2012; Manen, 2017; St. Pierre, 2016). St. Pierre (2016) states that social science researchers tend to rush to application, thereby carelessly using “a concept from one ‘grid of intelligibility’ or ‘system of thought’ in another” without studying the underlying history, philosophy and politics. Unlike authors such as Paley (2017) and Giorgi (2009), I do not advocate a sharp distinction between phenomenology as philosophy and phenomenology as qualitative research approach. Both are focused on the phenomenality of human experiences through an attitude of wonder. Moran and Mooney’s Phenomenology Reader (2002) provides a good overview of the diversity of phenomenological thought. 1

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In this chapter, I will discuss bodiliness, a central feature of phenomenology, in the context of care ethical empirical research. Care ethics values the particular bodily experience of the people involved in care practices and acknowledges the importance of the body in moral reflection. Care ethicists such as Patricia Benner and Maurice Hamington have thematized the embodied dimension of care. However, as far as I know, little is written on what embodiment as epistemological presupposition implies for our qualitative research practice. Looking at phenomenological research practice in general, it is striking that bodiliness has been little discussed. Although virtually any phenomenological researcher would agree with the assertion that perception and experience arise from our bodily engagement with the world, this bodily engagement (of both the researcher and the participant), contrary to philosophical phenomenology, is rarely explicitly thematized in phenomenological research studies.2 Rather, phenomenological research is often displayed as a mere cognitive enterprise conducted by a distant and interchangeable researcher who systematically analyzes others’ experiences. In addition, it is often suggested that experiences are something psychological and that speech is the straightforward vehicle for expressing them. This chapter discusses both the bodiliness of the researcher and the participant in relation to each other. I will first describe the bodily character of lived experiences and understanding. In the second part, I will illustrate how these insights can be converted into research, providing illustrations from my own research practice. With this chapter, I aim to show how phenomenology can help care ethical researchers to address bodiliness in their study.

The meaning of lived experiences Phenomenology is concerned with “lived experiences” which announces the intent to explore directly the pre-reflective dimensions of human life; life as we actively and passively live through, An important exception is the work of Linda Finlay, Kate Galvin and Les Todres. 2

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before we take a reflective view of it. Hence, the term “lived experiences” locates the sensation of the experience in the body. Phenomenology studies the world from a first-person perspective, in contrast to the third-person perspective usually adopted by the empirical sciences and which distances itself from experience. This focus on the first-person perspective does not mean that phenomenology is an individual, solipsistic or private affair. Indeed, the first-person’s perspective is itself constituted and conditioned by the world it discloses. In later work, Husserl (1952) describes this first-person perspective in terms of Leib, conditioning the possibility of perception since it provides a zero-point for movement and orientation, an embodied “here” from which all one’s actions set off (Slatman, 2014). This zero-point is never absolute because it is itself constituted through experience. Leib must be understood in relation to Körper, which refers to our body as an object, as an extended thing in space. Merleau-Ponty further developed these ideas in Phenomenology of Perception (1962) in which he states that the body is not a mere object but a form of consciousness. What we ordinarily think of as the mind is grounded in bodily subjectivity (Luft & Overgaard, 2012, p. 107). On a primordial level it is our moving, sensing and adept body that discloses the world. Merleau-Ponty (1962) describes the body as our general medium for experiencing a world as it is “the horizon latent in all our experience and itself ever-present and anterior to every determining thought” (p. 106). The philosopher Eugene Gendlin reflects in his work on the tension between language and the lived body and refutes the prevailing idea that an experience is something that occurs in someone’s mind. He states that the intimate inhabiting that the lived body experiences in its interaction with the world is the primary source of knowing that makes language meaningful and possible. This bodily character of experiences highlights the passive aspect of experience as it refers to something that befalls us, that we undergo. And often, the bodily depth of what one has lived through, is “more than words can say”. Gendlin uses the term “felt sense” to describe this bodily experiencing, indicating something more interactional than subjective

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inner bodily sensations. Felt sense is not the feeling of “‘stuff inside’ but the sentience of what is happening in one’s living in the outside” (Gendlin, 1997, p.  41). He makes clear that experiencing is not a psychological process but “the process of concrete, bodily feeling, which constitutes the basic matter of psychological and personality phenomena” (Gendlin, 1964, p.111). Phenomenology is therefore described as a way out of the Western egocentric predicament (Sokolowski, 2000). For Descartes, consciousness resided in the human mind, hence, meanings were thought to have been created in the mind, separate from the public and social sphere. However, phenomenology, by means of its doctrine of the intentionality of (embodied) consciousness, shows how we are always meaningfully connected to the world and emphasizes that individuals are not experiencing phenomena in isolation or in a social vacuum. The aim of phenomenological research is not merely to describe lived experiences, as is sometimes thought by researchers who assume that it is sufficient to provide various detailed descriptions that remain close to the words of the participants. In accordance with the aim of Husserl, the phenomenological process of understanding participants’ experiences is about opening up meanings. The task of the phenomenological researcher is “moving beyond what the participant says or what is written down by the researcher to what is revealed in the telling or observing and to capture the implicit horizons of meaning” (Finlay, 2014, p. 125). Merleau-Ponty (1964/1968) states that the meaning is not on the phrase like the butter on the bread, like a second layer of “psychic reality” spread over the sound: it is the totality of what is said ... it is given with the words for those who have ears to hear. (p. 155)

Meaning is the invisible thread that connects the human being to the world and it is because we are in the world that we are condemned to meaning (Merleau-Ponty, 1962). We do not see neutral objects but we see meaningful objects. How we perceive the world, i.e. how the world appears to us, is co-structured by the actual needs and possibilities of our body. I see a bakery on the corner of the street

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when I am hungry and the same bridge of which I always admire the architecture becomes a threshold, if not a mountain, when I get there at the end of the marathon. Even when I have just eaten I may see the bakery because, for example, of its bright red painted wall. Likewise, the stench hanging around a patient or time pressure in the hospital affects the perception of a nurse. Meaning thus is about the link between me as a person and what the world offers. Depending on my history, current bodily needs, my plans and the context in which I find myself, certain things attract me or just repel me. Meaning describes how we are, how we experience the world and neither belong to the object nor the subject but to the in-between structure of the lifeworld. Meanings are embedded in lived experiences and are being born from a situation, rather than brought to the situation (Dahlberg & Dahlberg, 2004). Indeed, the same experience, such as boredom or anxiety, can mean something else for the same person in a different context. A situation is lived through by an individual and this suggests that an experience is perceived individually. For me as a researcher the experience is displayed by words (interview) or, when I take part in the situation (observation), I become bodily aware of the experience. It seems that between the experience and its meaning for the other, on the one hand, and my grasp of it, on the other, lies a gap I can never entirely ford. However, because of our existential connectedness, i.e. we belong to the same world by means of our body, we are connected with the other and able to understand something of his or her perspective. The phenomenologist Schmitz also rejects the idea that experience is a strictly individual matter and describes experience as a form of partaking and being enveloped in atmosphere and moods (in Vosman, 2017). The meaning of our experiences or those of others, however, will always partly be hidden because as soon as we turn our experience into words some sort of reflection is involved and we inevitably immediately have stepped away from the “living moment”. The best we can do is to retrospectively try to recover the experience and then reflect on what the experience was like in that elusive moment (Van Manen, 2017). As a consequence, we can at

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most “have an echo or trace of understanding” of a certain experience (Hamington, 2004, p. 55).

Understanding as an intuitive process The opening up of meaning, i.e. answering the question what this experience is like (Van Manen, 2017) requires reflection and interpretation (analysis) of lived experiences. A number of phenomenological research approaches describe a series of steps for performing a phenomenological analysis (e.g. Dahlberg et al., 2008; Giorgi, 2009; Smith et al., 2009). However, as Max van Manen (2017) rightly notes, following these steps does not automatically lead to more insight into the meaning of the experience. Rather than a mere cognitive process in which the researcher is busily coding and structuring the data, understanding is first and foremost an embodied process. Phenomenology assumes that a certain attitude is required to access the meaning of lived experiences. The turn to the phenomenological attitude is called the phenomenological reduction, usually framed as bracketing. The term reduction should not be confused with its daily connotation of reductionism understood in terms of abstracting, codifying and shortening. Rather, in phenomenology, reduction has a positive meaning, leading us back (re-ducere) to the mode of appearing of the phenomenon. This can be achieved by the epoché (suspension) referring to the mental act by which we look at things that appear to us. We refrain from making judgements about the factual and we wonder about the meaning of our experiences. The reduction thus consists of two methodical moves that complement each other (Van Manen, 2014). Phenomenological understanding must be distinguished from traditional intellectual understanding which is confined to “true immutable natures.” Understanding is seen as based on sensation rather than the intellect and is therefore an embodied process. Van Manen (2017) describes understanding by means of “insights.” Accordingly, Norlyk et al. (2011), drawing on the work of the Danish philosopher K.E. Løgstrup, characterize phenomenological research as a creative process in which “flashes of insight” occur. Van Manen (2017) points

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out that phenomenological insights do not depend on the creativity of the researcher. In a creative act, the subject is the creator. A phenomenological insight, however, may happen to me as a gift, a grace—an event that I could neither plan nor foresee. Describing phenomenological research as an intuitive process rather than a creative process is therefore more appropriate. Knowing by intuition is the ability to acquire knowledge without a full understanding of how this knowledge is acquired. Norlyk et al. clarify that for Løgstrup there is a close relationship between an impression and a flash of insight. An impression involves the ambiance of a situation or experience and carries a tuned and prelinguistic meaning. Hence, an impression moves us bodily, it works on us and we grasp something. For instance, some words or phrases of a participant may stand out for us. An impression reminds us of something, for example something from our own experience, and facilitate a new understanding, i.e. it lets us think of something that we have never thought of before. What we are reminded of occurs as a spontaneous, intuitive flash of insight. Although an intuitive flash of insight appears suddenly, it is not random and it does not come without preparation and hard work. Phenomenological analysis has therefore been described as a state of active passivity (Dahlberg et al., 2008; Van Manen, 2014). Van Manen (2002, 2014) emphasizes the importance of writing in this intuitive process because through writing we come in touch with something. Writing, he argues, is “not just externalizing internal knowledge, rather it is the very act of making contact with the things of our world” (2002, p. 37). This act of making contact, I believe, is a significant difference between writing and coding and reflects an embodied process rather than a technique. As a qualitative analysis tool, coding is often used in a phenomenological analysis. Coding means marking sections of data and giving them labels or names (Holloway & Wheeler, 2010, p.  286). Often, researchers single out words or phrases that are used by the participant (in vivo coding). This is, however, in contrast to opening up meaning as described above. Moreover, coding calls for an attitude which is at odds with a

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phenomenological attitude. The activity of coding is focused on reducing, organizing, summarizing, labelling and categorizing the data and it is a rather cognitive and technical act upon the data. In the following, I will describe phenomenological analysis as a writing process in which the entire body of the researcher is involved aiming to fathom the data from within. Although writing is of course an important component in every qualitative study, it often takes place in the last phases of the research. The writing is then no longer focused on understanding but rather on writing down the results.

Bodiliness in conducting care ethical phenomenological research: two illustrations In this part, I describe how I addressed bodiliness in two distinct phenomenological studies. This will further clarify what we may gain when we take the embodied dimension of experiences seriously, as well as the role of our own body, in understanding others’ experiences. It  will also illustrate how we can facilitate the process and create conditions in which understanding may occur. But before doing this, I will reflect on the (care ethical) need to conduct these studies in the first place. The first study concerns my PhD study that aimed at a better understanding of the lived experiences of older hospital patients. The second study was concerned with the bodily experiences of people with Multiple Sclerosis. Due to ageing of the population, hospitals must serve a growing population of older patients. However, numerous studies show that hospitalization is a drastic and hazardous event for many older people in both functional and psycho-social terms. Although this has led to an increased attention to older patients, because of the dominating biomedical perspective, the question “what is it like to be old and hospitalized” is rarely asked. Phenomenological research enabled me to reveal this perspective as it “offers individuals the opportunity to be witnessed in their experience and allows them to ‘give voice’ to what they are going through” (Finlay, 2011, p. 10). Psychological approaches have widely shown that despite the negative impact of MS, it is possible for patients to positively influence

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their well-being. Although I recognize the value of these studies I remark two significant drawbacks: First, these studies tend to view living (well) with MS as merely an individualistic matter without acknowledging that individual experiences are both a response to and a reflection of a social and cultural context. Second, most studies strongly reflect a body-mind dualism by approaching processes of adjusting to MS as merely taking place in the mind without thematizing someone’s relation to his or her own body. In fact, the body is characterized as meaningless material. The problem with dualism is that one is always subordinate to the other. In this case, the strong focus on attitude is at the expense of attention to the body with MS. This does not do justice to the lived reality of people with MS who have to deal with their ever-changing body. This study examines how people with MS experience their body in daily life, thereby studying the (broken) relation between self and body from a phenomenological perspective and exploring whether and how this relation might be restored, and providing clues for good care.

Taking part in experience: shadowing older hospital patients To gain insight into older patients’ experiences, I shadowed them during their hospital stay. One reason to opt for shadowing was that it was unlikely that my intended participants, frail elderly hospitalized people, were able to meet the requirements expected to be met by participants in phenomenological interview studies: participants must be open to their experiences, have the ability to maintain focused on the phenomenon and have the narrative competence to give a detailed and logically structured account of their experiences (Kvigne et al., 2002). In order not to exclude certain participants beforehand just because they would have difficulties with expressing their experiences within a given time, shadowing seemed the most appropriate method. Yet, the main reason for shadowing is that this method enables one to take into account the bodiliness of the participant (shadowee) as well as the researcher. Shadowing gives a more central role to bodily expressions of the shadowee since both articulated speech and non-articulated speech are considered as ways of expressing

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meaning. The importance of body language is twofold: on the one hand, bodily expressions show how something is experienced and is the starting point for questions; on the other hand, bodily expression can enrich what is said by another person. Mrs. Cannel is lying in bed and it is quiet in the room. She yawns and her eyes stay dull. Her body shows lethargy. “Imagine you just lay here for months” she sighs. Everything indicates that she finds it very boring in the hospital. (…)

The intimacy of shadowing suggests that the researcher may experience the phenomenon in a similar, but not identical, way as the shadowee. The emotions felt in the field provide insight into meaning. Mrs. Cannel talks about the trees and the cars on the road she sees from her hospital bed through the window. I hear the clock ticking and the hands point four o’clock; the time when the change of shift occurs. The corridor is empty. It is silent. A nurse passes by. After a while, she suddenly says, more to herself than to me: “How many steps would walk through the corridor every day?” I feel myself being swept into the rhythm of Mrs. Cannel and it feels like I am experiencing something of the boredom she goes through.

The following occurs in the second research encounter. At that time, Mrs. Cannel has been in the hospital for 4 days. When I enter the room around 11.00 in the morning Mrs. Cannel is sitting at the same spot as yesterday. She is dressed up (patients usually wear pajamas or a nightgown) and the curtains are half closed. Although it is a four-person room, there are no other people now. “It’s boring here” she says, just as she said the previous day. I ask what her daily life usually looks like. “We are together and we go outside in the evening (in the corridor) chatting to other people. It must be laziness as I do not feel like reading or anything.” (…) “I would like to close my eyes” she says, “I would rather lie in bed than sit in a chair. If they (nurses) come to ask if I want to go to bed, then I will. I am so tired. I do not know whether it is laziness or apathy.” When asking how the weekend was, she answers: “Boring”. Last week she mentioned this word a few times and it seems to be a problem. Mrs. Cannel had visitors in the morning of the previous day and that made her realize that it was weekend. “Normally, at home, the newspaper makes you aware of that”. (Fieldnotes, 2011)

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These field notes show how I as a researcher became bodily affected by the atmosphere in the hospital room and the mood of Mrs. Cannel. 3 As understanding is based on sensation, the body of the researcher serves as an entry point to understand the bodily experiences of shadowees. I could never have fathomed the meaning of boredom without being bodily present at the hospital with Mrs. Cannel. Since our body does not disappear when we leave the field, the embodied character of shadowing informs the insights later generated and reported (Gill et al., 2014). Also, since I shadowed older people during their entire hospital stay, a relationship came into being. Trust and familiarity appeared essential for the older people to open themselves to me. Almost every person I asked to participate in the study responded by saying that they were satisfied with the care being given. Shadowing, in contrast, gave me an entry to their existential experiences in the hospital which I described as “feeling an outsider left in uncertainty” (van der Meide et al., 2015). Shadowing thus enables us to discover actual experiences in a caring way in accordance with the perspective of care ethics.

From transcript to meaning: the bodily experiences of people with Multiple Sclerosis In phenomenological research, we are interested in detailed and concrete stories because it is by means of stories and anecdotes that people narrate their experiences. If the interview material lacks sufficient concreteness, researchers must overinterpret, speculate or rely on personal opinion during the analysis (Van Manen, 2014, p. 317). For this study, we prepared interview questions and asked how the body was experienced or appeared in a number of daily situations.4 Asking for actual events is helpful to invite the participant to share an experiential account of a moment in a particular place in time (Finlay, 2011; Van Manen, 2014; Slatman, 2014). 3 These excerpts are discussed in detail in my paper: Giving voice to vulnerable people: the value of shadowing for phenomenological healthcare research. Meide, H. van der., Leget, C., Olthuis, G. (2013). Medicine, Health Care and Philosophy 16 (4), 731-737. 4 I conducted this research together with Pascal Collard and Truus Teunissen.

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The movement from research material such as interview transcripts or observation reports to a deeper understanding and a rich description of the phenomenon is complicated. In this section, I describe the movements that unfolded during the analysis of the interviews in the MS project. The approach to this study was mainly built upon the work of Max van Manen and his phenomenology of practice. Hence, writing is a crucial component of the analysis. (The process is visualized in figure 1 and consists of four movements in the form of a hermeneutic spiral). The four movements are reflective methods supporting the researcher in the search for meaning in the text. At the same time, the purpose of these movements is to create (thinking) space for flashes of insight that ultimately may lead to an understanding of the phenomenon.

Figure 1: Movements in the phenomenological analysis.

Immersion in lived experiences The analysis starts with reading the transcripts5 and listening to the audio files. By not immediately doing anything actively, the data can 5

In this text, the term “transcripts” can be replaced by “field notes”.

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“speak” to the researcher. After reading the transcripts as a whole, each transcript is read again, but with a focus on each sentence or a number of sentences separately. The researcher writes his own thoughts, sensations, questions and comments in the margin. In phenomenological terms, this is about surfacing someone’s fore-understanding. Pre-understanding make up a foundation for understanding but can also stand in the way of openness. Phenomenological researchers are engaged in the phenomenological reduction during the whole research process. We often do not know our fore-understanding until we come in contact with the phenomenon. Then, emotional responses or what appeals to us signal what matters to us. Thus, phenomenological analysis including the reduction is an embodied process. We understand experiences in a way that is shaped by our bodily reality. Also, in conversations with other researchers we become aware that certain aspects speak to our imagination while others are overlooked. When reading the transcripts, it becomes clear that not all text is relevant to the study. The transcripts contain a lot of “rumble”. That is text in which participants talk about issues that are not related to the experience being investigated, share factual or general information or talk reflectively about their experiences. Rumble is inevitable and the next step, therefore, is to identify the text which seems to tell us more about the phenomenon and in which the participant gives an experiential account. Composing textual portrayals In this movement, the amount of text of the transcripts is reduced to lived experience descriptions. Although the amount of data is reduced by composing textual portrayals, the main goal of this movement must be understood in the Husserlian conception of the reduction as leading back to the meaning structures of the phenomenon. I call these lived experience descriptions textual portrayals because they are evocative and describe an aspect of the experience in a language that speaks to our imagination. Words are, as it were, brought to life and, as is shown in the following textual portrayal, provide a glimpse into the phenomenon.

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My lower leg and my left arm feel numb. It’s like I don’t feel myself. As if I’m wearing thick ski socks. If I dry off other parts of my body, it feels different. It’s like I dry off my neighbor’s leg, it feels far away. It’s like I wear jeans around my legs all the time. Now, after 14  years of washing and drying off and getting the input of that other feeling again and again, it starts becoming familiar. Slowly I think, my legs feel like that, I’m losing the old feeling and they become my own legs more and more. A textual portrayal usually describes one event in detail using different quotes. These quotes do not necessarily follow each other chronologically in the transcript because the same experience can often be discussed at different times in the conversation. Adjustments in the text can be made such as inserting linking sentences, converting the text to present time, and using personal pronouns. The actual content can be changed to make the phenomenological content more evocative. The vocative refers to the event that a text speaks to us, when we experience emotional and ethical responsiveness and when we feel addressed (Van Manen, 2014). In this way, textual portrayals can support the researcher in the analysis by contributing to intuitive understanding. A different researcher could have uncovered different textual portrayals but this is not a problem as long as we recognize that every revealing has his concealing. The function of textual portrayals is to draw attention to the multiple meanings within phenomena and draw the reader or the listener into new understandings (Crowther et al., 2016). Phenomenological thematization and reflective writing The textual portrayals form the basis for a phenomenological thematization and the themes form the beginning of a structure for the final description in which the phenomenon is explicated. Explicating is a phase of synthesis and integration, of clarification and revelation, where emergent themes are pulled into larger themes and (cultural) narratives (Finlay, 2014). In this writing, the researcher tries to make the reader see the phenomenon in a certain way while at the same time showing the ambiguities. The text is closed in the sense that one interpretation

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is provided, but open in the sense that it is acknowledged that this interpretation always remains provisional, partial and that much remains unsaid. Phenomenological philosophy and other related literature can be well used in this phase. These sources might function as insight cultivators (Van Manen, 2014) allowing us to see new possibilities, to transcend the limits of our interpretive sensibilities and to widen our horizon for interpretation. Smythe et al. (2012) also emphasize the importance of literature by describing it as an essential dialogical partner from which scholarly thinking and new insights emerge. We used Schmitz’ notion of an “abstraction base” to reflect on the theme of “being a non-productive body” that emerged in our study. An abstraction base refers to a set of fundamental ideas or concepts so deeply entrenched in common experience that they provide a framework of intelligibility in which all things appear in experience and shape how they are understood and interpreted (Schmitz et al., 2011, p. 244). For people with MS the idea of being “a productive body” can be seen as a contemporary abstraction base resulting in feelings of guilt as the following textual portrayal illustrates. Since I don’t work, I can do fun things. But that makes me feel guilty because I can go to the park for a nice picnic on a sunny weekday. That’s not how it should be as I should work. So, it sounds like fun, but it is not fun.

Conclusion Care ethics provides an alternative to biomedicine by viewing the body as the epistemological locus of morality. This focus should also be reflected in the empirical research conducted by care ethicists. I have shown the bodily character of experiences and understanding and how this can be addressed in phenomenological research. With our care ethical phenomenological studies, we do not only want to produce (scientific) knowledge but we also want to change care practices and have an impact on our society. Our research can only have an impact when it resonates, i.e. when it reflects a comprehensive perspective of the (embodied) experiences of the people being studied and when “the audience” is touched by the findings. Understanding begins when we feel bodily addressed.

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Merleau-Ponty, M. (1962). Phenomenology of Perception. (C. Smith, Trans). London & New York: Routledge. (Original published 1945). Merleau-Ponty, M. (n.d.). The visible and the invisible (A. Lingis, Trans.). Evanston: Northwestern University Press. Norlyk, A., Dreyer, P., Haahr, A., & Martinsen, B. (2011). Understanding the creative processes of phenomenological research: The life philosophy of Løgstrup. International Journal of Qualitative Studies on Health and Well-Being 6 (4), 1–8. https://doi.org/10.3402/qhw.v6i4.7320 Schmitz, H., Mullan, R. O., & Slaby, J. (2011). Emotions outside the box—the new phenomenology of feeling and corporeality. Phenom Cogn Sci 10, 241–259. Meide, H. van der., Leget, C., Olthuis, G. (2013). Medicine, Health Care and Philosophy 16 (4), 731-737. Slatman, J. (2014). Multiple dimensions of embodiment in medical practices. Medicine, Health Care and Philosophy. https://doi.org/10.1007/s11019-014-9544-2 Smith, J. A., Flowers, P., Larkin, M. (2009). Interpretative Phenomenological Analysis. Theory, Method and Research. Los Angeles: Sage Publications. Sokolowski, R. (2000). Introduction to Phenomenology. Cambridge: Cambridge University Press. St. Pierre, E. A. (2016). The empirical and the new empiricisms. Cultural Studies— Critical Methodologies 16 (2), 111–121. van der Meide, H., Olthuis, G., & Medical, A. (2015). Feeling an outsider left in uncertainty—a phenomenological study on the experiences of older hospital patients (7), 528–536. https://doi.org/10.1111/scs.12187 Van Manen, M. (2002). Writing in the Dark: Phenomenological Studies in Interpretive Inquiry. London, Canada: Althouse. Vosman, F. J. H. (2017). The moral relevance of lived experience in complex hospital practices: A phenomenological approach. In Heuvel, S. C. van den, Nullens,  P., & Roothaan, A. (Eds.), Theological Ethics and Moral Value Phenomena (pp. 65–92). Abingdon, NY: Routledge. Vosman, F., & Niemeijer, A. (2017). Rethinking critical reflection on care: late modern uncertainty and the implications for care ethics. Medicine, Health Care and Philosophy. https://doi.org/10.1007/s11019-017-9766-1 Walker, M. (2007). Moral Understandings A feminist study in ethics. Oxford: Oxford University Press.

“Being professional is also daring to be a human being”: Kari Martinsen’s phenomenological approach to care and its relevance to medicine Elin Håkonsen Martinsen

Introduction The subject of care ethics has traditionally exerted an influence in areas related to nursing, but it has not had the same influence on the theoretical frameworks physicians mainly rely on to guide their ethical choices. However, as the emphasis on care ethics evolves and its areas of use are extended, caring concepts are also being discussed and incorporated to a greater extent in the medical ethical discourse (Branch, 2000; Cates & Lauritzen, 2001; Cluff & Binstock, 2001; E. H. Martinsen, 2013; Van Reenen & Van Nistelrooij, 2017). In Norway and Scandinavia, the Norwegian nursing scientist and philosopher Kari Martinsen’s (2003a, 2003b, 2003c) scholarly works have influenced much of the current understanding of nursing care and ethics. Martinsen is influenced by phenomenology, and of particular importance to her thinking are the writings of the Danish philosopher and theologian Knud E. Løgstrup (1956, 2008). Despite being influential in the realms of nursing and nursing ethics in Scandinavia, Martinsen’s works are not well known in medicine or in the field of medical ethics. Investigating Martinsen’s philosophy of care within a medical context may thus help us bridge the gap between related research traditions in medicine and nursing as well as contribute to further development in the fields of care ethics and medical ethics. Martinsen’s works are published mainly in

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Norwegian, and discussing her works outside a Scandinavian setting adds important perspectives to the international debate on care and care ethics. In this chapter, I will elaborate on Kari Martinsen’s philosophy of care from a medical point of view, discussing how her conceptualization of seeing with the perceiving eye—understood as openness and receptivity—may be combined with the more traditional investigative gaze in meeting with the patient. This is important, as I claim that both ways of seeing the patient are important for quality care. In order to accomplish this, I first elaborate on Martinsen’s phenomenological analysis of care as well as her understanding of perception and its relevance and importance in clinical encounters. I further discuss her conception of perceiving and recording, relating them to a medical context and arguing that both ways of seeing and approaching patients are important in medicine. Finally, I aim to discuss how a perceiving and recording approach may be combined in the clinical encounter and during the diagnostic examination of the patient. To illustrate my points, I use examples both from my own practice as a physician and from the literature.

Kari Martinsen’s phenomenological approach to care Although Martinsen’s point of departure is the philosophy of nursing, her analysis focuses more on the relationships between patients and health care professionals in general than on the particular relationship between patient and nurse. Her focus is not on the specific tasks of nursing but rather on the processes that take place in the relationship between a person who is ill and in need of help and a person who is there to help. She is concerned about the effect that patients’ subjective expressions of illness have on health care professionals. I  therefore find that her analysis—of how meeting people in need affects the one who is there to help—is just as relevant to the practice of medicine as it is to nursing. This is regardless of whether the encounter is in the GP’s office, a hospital ward, or a nursing home. In relying on the Danish philosopher and theologian Knud E. Løgstrup, Martinsen (2003c) anchors her phenomenological analysis

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of care in the tradition of phenomenology of creation. This tradition has its roots in a Judeo–Christian view of human life and creation, according to which there is a created, meaningful structure and “architecture” to life itself; life has intrinsic significance that reveals itself in human relationships. The basic conditions of life are given to humans and are not the result of any human effort or achievement. This raises the question of whether this perspective constitutes a theological perspective and presupposes Christian faith. In response to this, Martinsen argues that the idea of creation can be understood philosophically as well as theologically, as an ethics of reserve1, in which human beings hold themselves back and are open to discovering what is given to them, that is, what Løgstrup sees as the basic conditions of existence (Martinsen, 2003b). Care constitutes one of these conditions, and rises to expression through human relations and phenomena such as hope, trust, openness of speech, and mercy. Løgstrup calls these “spontaneous sovereign life-utterances”, thus conceiving of them as pre-cultural phenomena (Løgstrup, 1956, 2008). To understand life as created requires a radical change of perspective on the relation of oneself to the other (Martinsen, 1991). It  allows for an attitude of holding oneself back and “receiving the other as a gift” (1991, p. 9). As I see it, this attitude of “holding back” constitutes an important insight into the phenomenology of creation that may be conceived of as independent from the theological question of whether or not there exists a God of creation. By meeting the other with such an attitude of reserve, the other is allowed to emerge in his or her own right, without being “conquered.” This reserve and receptivity is part of what Martinsen means by perception. Within a phenomenological frame of reference, Martinsen’s use of the term perception is related to the idea of phenomenology as “being open to the world.” It is important not to confuse this way of understanding perception with the way the term is used in, for instance, the field of psychology, where it refers to how we organize the sensory world into The expression “reserve” is translated from the Norwegian expression “tilbakehddenhet,” meaning an attitude of restraint or of holding space. 1

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a coherent scene consisting of real objects, not just sensory impressions (Gleitman, 1992). According to Martinsen, perception is characterized by an openness towards the world in which sensations and emotions work together. It represents a “fundamental openness towards the world, significant and precultural” (Martinsen, 2006, p. 86). This understanding of perception clearly shows the influence of phenomenology on her thinking about care: in Edmund Husserl’s transcendental phenomenology and theory of time-consciousness, a central theme is how consciousness is constantly modulated by impressions; the claim is that we have a pre-theoretical affective access to the world that is conditioned by receptivity and passivity (Gallagher & Zahavi, 2013; Nortvedt, 2008). This is also central in Levinas’s ethical metaphysics and his phenomenology of the face (Levinas, 1991). Drawing on the work of Emmanuel Levinas (1991), Edmund Husserl (1964, 1998), Dan Zahavi (1999), and John E. Drabinski (2001), Per Nortvedt (2008) describes a state of sensibility, which he understands as “the basic state of pre-intentional consciousness characterized by passivity and receptivity” (p. 211). Sensibility may be understood as our presence in the world through our senses, where not only our interpretation of an impression but also the impression itself is important, moving both our senses and emotions. As I interpret Nortvedt, I find his understanding of sensibility similar to Kari Martinsen’s understanding of perception and what she denotes the perceiving eye (Martinsen, 2006).

The perceiving and the recording eye In her essay “Seeing with the Heart’s Eye”, Martinsen (2006) explores different dimensions of the clinician’s gaze, drawing a distinction between the process of perception and the process of recording, between a perceiving eye and a recording eye. She relates these two different ways of seeing to the biblical story of the Good Samaritan, which she uses to illustrate how a perceiving eye can facilitate care in the clinical encounter. Martinsen (2006) contrasts this perceiving eye with the recording eye. Recording occurs when a person puts herself in an outside position, classifying, systematizing, and differentiating,

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working within the framework of an existing conceptual system (Martinsen, 2006). The recording eye is reductionistic and neutral, and it may reduce normal characteristics, such as a laughing face, to clinical signs, characteristics, and marks. According to Martinsen (2006), the disinterested, observing gaze is too busy classifying to heed the call to take responsibility for the life of the other whom we have in our gaze: “The classification overlooks the demand. The concepts and their internal logical order block the way, so that we do not see the other as a living person” (p. 105). Here Martinsen, referring to the life of the other whom we have in our gaze, reiterates Løgstrup’s well-known idea that we always hold other people’s lives in our hands (Løgstrup, 1956). Martinsen’s description of the recording eye is inspired by Løgstrup’s (2008) concept of the eye of the epoch, which constitutes part of his critique of modernity. Martinsen echoes as well the medical historical works of Michel Foucault and his analyses of the medical gaze (Foucault, 1994, 1995; Martinsen, 2006). Foucault coined the term medical gaze to refer to the dehumanizing way in which the medical profession has come to separate the body from the person.

Medicine’s eye Even though conditions in modern hospitals have changed since “the birth of the clinic” as described by Foucault (1995), today’s health care professionals—first and foremost physicians—still build much of their knowledge using the “voyeur method of the human observatory—seeing without being seen” (Martinsen, 2006, p. 109). Patients are observed from the outside, put in specific rooms for examination with the aim of enabling the physician to classify—divide, sort, categorize, and record— in order to reach a diagnosis. This perspective is evident if we refer to a textbook on clinical examination for medical students in which the authors point to how the examination really begins from “the moment you set eyes on the patient” (Epstein et al., 2008, p. 20). We see here that the medical exploratory gaze operates within a fixed framework, systematizing, differentiating, and classifying information about the patient within

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a predefined schema. From the first moment the physician sets eyes on the patient the examination begins, registering body language, clothing and hygiene, stature, posture, and handshake. Conversation with the patient usually follows an “anamnestic roadmap”, and there is often little time or opportunity to deviate from this map. If the patient does start to talk about something outside these parameters, the physician often employs strategies for redirecting the patient in order to focus on the anamnesis and reach a conclusion for the consultation. The usual way of approaching patients in medicine leaves little room for perception understood as an “openness toward the world” (Martinsen, 2006). On the contrary, the interaction may often be fixed, following a scheduled plan, with the physician aiming at “disciplining” the situation so as to be able to complete the consultation. Empirical research also documents this way of seeing in medicine. In their study “Clinical Essentialising: A Qualitative Study of Doctors’ Medical and Moral Practice”, Kari Milch Agledahl and her colleagues recognize the uniformity of physicians’ ways of seeing patients, pointing to how physicians actually “essentialize” patients’ stories by breaking them down into concrete complaints and categorizing the symptoms in medical terms (Agledahl, Førde, & Wifstad, 2010). In another study, Agledahl et al. (2011) show how doctors themselves under observation, actively directed the focus away from the patients’ existential concerns and towards medical facts, rarely addressing the personal aspects of a patient’s condition. They conclude that the main failing of patient–doctor encounters is not a lack of courtesy but the moral offense patients experience when existential concerns are ignored: The doctor avoids obvious existential concerns: when the patient talks about the tumor, his doctor does not address the underlying fear but asks about symptoms. Likewise, when the patient’s increasing tiredness is brought up, he is made to quantify his activity levels. Explicit worries are met with medical answers, and even a patient’s dying process is even described as “a catabolic condition”. The tacit existential dimension appears uncomfortably present at the end when the fears that are unaddressed seem to prevent the patient from leaving. (Agledahl et al., 2011, p. 652)

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The description that Agledahl et al. offer here may be said to be consistent with Martinsen’s description of the recording eye, by which tiredness is measured quantitatively and conceived of as a catabolic condition. This illustrates how physicians confine themselves to their medical repertoire when addressing their patients’ suffering. The physicians continue recording the patients’ conditions, and by the process of “essentializing” and by actively directing their focus away from patients’ existential concerns, they never enter the perceiving range of life (Martinsen, 2006).

The consequences of recording and perceiving This kind of recording activity by the professional’s trained eye is necessary in order to understand a patient’s medical condition and to reach a diagnosis. However, by only recording, physicians risk becoming indifferent to the other; this way of seeing patients, I argue, excludes emotions for the other—seeing emotions—and may lead to an objectification of the other. For Martinsen (2006), a seeing emotion is an emotion for which perception opens (p.  74). To further describe such emotions, she uses expressions like “being pained in the gut” or “touched by” or “struck” by the other (2006, p. 84). Through a recording eye, the other may be seen as an object or as a completed fact, and this interpretation may threaten the other’s integrity (Kemp, 2000). Being seen as an object may be a painful and damaging experience: The one who is seen, without mattering to the one who sees him, experiences it as painful at first, then closes himself and his pain. One is seen in such a way that one shrinks. One may feel seen through and undressed, attacked and conquered by a gaze which is a non-participatory, staring, “look for” gaze. Life courage is reduced and emotions become space constricting. (Martinsen, 2006, p. 109)

Furthermore, a caring approach may sometimes be epistemologically essential in the clinical encounter. Along with a moral argument, then, there is an epistemological argument: in being professional, a physician’s own emotions are assets. By being aware of his or her own seeing emotions when meeting with the patient, the physician is able

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to capture important information regarding the patient’s clinical situation. By being open and nonjudgmental and having an attitude of reserve and receptivity, the physician may better be able to uncover the underlying concerns of the patient. Instead of rapidly ending the consultation once its initial purpose is resolved, the physician remains, being receptive to the patient and thus managing to hear the patient’s appeal for help. This way of seeing involves not only an openness to the patient’s vulnerability but also an openness toward the physician’s own vulnerability. It requires the development of an awareness in the doctor of her own feelings. Such an openness to affective cues in the clinical encounter may be a precondition for complete understanding of clinical realities, contributing to sharpening clinical intuition, which is necessary for competent medical treatment and care (Nortvedt, 2008). Entering “the perceiving range of life” in the GP’s office In one of her books, the Norwegian general practitioner Eli Berg (2005) describes a patient consultation in which she manages to see and perceive a patient in a different light than in her previous consultations with him, and she points to how this leads to a different understanding of the patient. The patient, Nilsen, is well known to her. He is a carpenter who has had problems with his back for many years. Berg now suspects that he is trying to get sick leave from his regular job in order to work off the books. Berg has known this patient for 15 years and does not like him very much. She knows he has problems with alcohol and aggression: “There is always a coldness following Nilsen,” Berg writes (2005, p. 105). This time his back pain seems even worse. He hobbles around with his face wreathed in pain. “Your acting is good today,” Berg says quietly (2005, p. 105). When the patient is finally seated in the examination room, his hair is wet from sweat, and his face and neck are flushed. Once again he complains about his “damn back”. I look at him, and suddenly it is as if I see past him, that his face in a way becomes transparent. I perceive a lived life. I think of his childhood; maybe he was not wanted when he arrived in this world. Maybe nobody showed him how valuable he was, gave him courage and a joy for life. …

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Suddenly, I perceive a human being thrown into the world without having asked for it. Like we all are. … I feel hit by a consciousness of how vulnerable we are as human beings. … In a split second this appears to me as an appeal, as a cry from time immemorial: Do you see me? Do you hear me? Without a reply we cannot live. (Berg, 2005, pp. 106–107, my translation)

Berg describes how the man’s unsympathetic traits are brushed aside and how she relates herself to a lived life, a person, a human being. For the first time the patient makes eye contact with her, and he cries. Then it is silent for a long time before he tells her that on the previous weekend he beat up and almost killed his girlfriend, with whom he had been living. He now lives alone; his now-ex-girlfriend owns the apartment, and he has lost his job because of alcohol. And his aching back torments him. Berg reflects on the radical change that she experiences in her meeting with the patient. “To like or not like, that is not what it is about for me this day,” she writes. “I am taken by surprise by something I cannot put into words” (Berg, 2005, p. 107). She puzzles, “how could I be so emotionally touched by this patient, whom I have tried to avoid for years?” (2005, p. 108). What Berg offers here is a description of how perception may open the way for a more comprehensive understanding of the patient. As Martinsen would express it, by being perceptually open in meeting with this patient, the doctor finds that her perception is condensed to an impression, which again is expressed in tone and gesture towards the patient. Berg is “in the situation with her whole strength in order to express [her] impression” (Martinsen, 2003b, p. 139), and through this she gains new insight regarding the patient and his condition. The insight Berg gains in her new perception of the patient is of a different kind than that which results from merely reflecting about possible causes of the patient’s pain. Entering into the perceiving range of life, Berg describes how she is struck and emotionally touched by the patient and the situation he is in, regardless of her previous dislike of him. She receives an impression from the patient and reacts to it by looking into his eyes for the first time. As Martinsen points out, we may express our impressions by a friendly gaze, a warm tone, or careful hands. And this expression of care establishes a new avenue

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of contact between patient and doctor: they make eye contact for the first time, and the patient reveals additional, useful information about his situation. What the patient reveals about his violent behavior towards his girlfriend is thus essential for the physician to understand him properly, in terms of investigating possible mental states or disorders leading to aggressive behavior. Thus, in the end, the doctor will be able to implement proper action, such as a referral to anger control treatment. It may be objected, though, that Martinsen calls on emotions as the main source of seeing, and she has been criticized for inheriting an uncritical understanding of emotions as a professional competency in nursing (Heggen, 2000). Even though health care personnel aim to be empathic and sensitive, they do not automatically act morally (Heggen, 2000). Emotions are not automatically a source of truth and right, and different emotions are likely to motivate different actions and care responses (Pulcini, 2017). For health care professionals, the need to deal with negative feelings for patients is as important as the positive effects of emotion (Baur, Van Nistelrooij & Vanlaere, 2017; Bourgault & Pulcini, 2018). Martinsen does not address the possible dark side of emotions in her work. However, nor is she a pure sentimentalist, highlighting only emotions; rather, she points to the importance of reflective understanding working in a “friendly interaction” with perception. It is difficult, in this friendly interaction, to distinguish between perception and understanding: they are “tightly interwoven” (Martinsen, 2006, p. 87). In this, Martinsen is in line with most other care ethicists in acknowledging the cognitive as well as the affective dimensions of care, and she places herself within an influential movement in moral philosophy that highlights the importance of human emotions (Blum, 1994; Bourgault & Pulcini, 2018; Gilligan, 1982; Nussbaum, 1990; Pettersen, 2008; Vetlesen, 1994). Later I will discuss how these two perspectives and ways of seeing patients may be combined in clinical work, arguing that the medical field needs to expand its way of seeing patients in the clinical encounter to involve a perceiving eye to a greater extent than what is the case today. But before doing so I must dig somewhat further into the tension between analyzing a patient’s complaints and seeing that

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patient as a person with a life lived, and explore the faults of “patientcentered” approaches.

How can the physician combine the perceiving and recording approaches during the examination of the patient? Even though I identify the medical gaze as a recording gaze, the situation today is not so one-dimensional, and there have been many attempts to include the patient’s perspective to a greater extent in medical practice. Patient-centered medicine represents but one example of such an approach, where the importance of pursuing the patient’s agenda, as well as the physician’s, is emphasized (Balint, 1957; Levenstein et al., 1986; Rosen & Hoang, 2017; Stewart et al., 2003). The essence of patient-centered medicine is to explore not only bodily symptoms and signs but also how patients experience their situations: the patient’s subjective interpretation is emphasized. To paraphrase Michael Balint (1957), a central and early proponent of patient-centered medicine; the illness perspective of the patient is explored. Emphasizing the illness perspective in medicine has been important in counteracting a disease-centered model and doctorcentered medicine, with its connotations of medical paternalism. However, despite many years of focusing on patients’ perspectives, medicine still needs a perceiving eye, I argue. Why should this be the case? As I see it, there is an important difference between Martinsen’s approach and the patient-centered model, and this difference involves the emotional involvement of the physician or nurse; that is, whereas the patient-centered method focuses on the patient’s perspective, allowing as much as possible to flow from the patient, Martinsen also highlights the effect on the health care worker of perceiving the patient. Thus, the perceiving eye entails having an openness towards the other’s situation and towards one’s own emotional response. This is a perspective that is not included in patient-centered models. This deficiency is also highlighted by the Norwegian and Danish scholars and general practitioners Kirsti Malterud and Hanne Hollnagel. In their 2007 article, “Avoiding Humiliations in the Clinical Encounter”, they signal the importance of taking the physician’s emotions

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into account in order to avoid humiliating patients during the clinical encounter. They refer to empirical studies that document experiences of humiliation among patients when they see their doctor, and they apply a philosophical and sociological analysis to explain the dynamics of unintended degrading behavior between human beings. Here, they point to the role of objectivism, detachment, and indifference in the dynamics of such degrading behavior, and they demonstrate how parallel traits may also be embedded in medical culture. Building on the works of the Norwegian philosopher Arne Johan Vetlesen (1994), who points to how emotional awareness is necessary for moral perception—which again is necessary for moral performance—Malterud and Hollnagel (2007) propose an awareness model of medical practice, in which the physician’s own emotions are taken into account as an important part of the physician’s agenda in the medical encounter. As I interpret the authors here, they argue in line with Kari Martinsen, pointing to the potential dangers of physicians displaying a recording gaze only, leaving out the sensuous and perceiving eye in the clinical encounter. Can their proposed model help us to reach an understanding of how to combine recording and perceiving approaches in the clinical encounter? The point of departure for the model proposed by Malterud and Hollnagel (2007) is the patient-centered clinical method, originally presented by Levenstein et al. (1986), whereby the tasks of the doctor are to identify and pursue both the medical and the patient’s agendas. However, according to their theoretical elaboration, the doctor’s self-awareness of her emotions is also essential. They therefore propose a shift of attention away from the doctor’s rationality—including professional knowledge and experience—and towards an emphasis on the doctor’s own emotions. In this way, they underline the necessity of including parallel agendas in the clinical encounter, where the perspectives of neither rationality nor emotions are omitted. I think this awareness model may help us to envision the importance of pursuing both a recording approach and a perceiving approach during the medical examination, whereby the process of recording corresponds to the doctor’s rationality as part of the doctor’s agenda and the process of perceiving corresponds

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to the physician’s aim of perceiving both the patient’s emotions and her own emotional responses. It leaves room for the physician’s perceptions and indicates how professional knowledge and the emotions of both physician and patient may lead in the end to a mutual understanding.

The double eye I do not intend here to offer a further recipe or a direction towards combining perceiving and recording approaches in practice. Instead, I believe the only way that physicians can raise their awareness of this combination in practice is through reflection. What physicians should aim at, according to Kari Martinsen (2006), is an eye of both perception and professional understanding, that is, the double eye— an eye that comprehends, perceives, and explores at the same time. The double eye is a participating, attentive eye, living in “the interaction between perception and understanding” (Martinsen, 2006, p.  92). It is “both receptive and exploring, and it is a matter of finding a balance and a calm between seeing openly and simply on the one hand and [learning] to see freshly and expansively on the other” (2006, p. 92). In light of the phenomenological tradition that Martinsen represents, aiming to describe in order to close in on the phenomenon in question may also be a way to approach this problem. In the following section, I will therefore describe how such a double eye may come to be expressed in different kinds of medical practice.

Tracing the double eye in medical practice Amaurosis fugax or a glint in the eye? While I was working as a physician in the medical department, I received an elderly woman who had temporarily lost sight in one of her eyes. She had an extensive medical record and a long list of prescribed medicines. When I read through her papers before the consultation, I envisioned myself meeting a severely impaired patient. However, when she entered my room, I met a lively little woman who was walking with a stick and a halting gait. She was cheerful, with a good

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sense of humor and a glint in her eye. I was taken by surprise due to my preconceived idea of her and the obvious disparity between the descriptions of her in the medical record and my own perceptions during the consultation. While writing her record later, I therefore aimed to convey her liveliness and not merely focus on all her physical ailments. I wrote under the present status, “86-year-old woman with a glint in her eye.” She was hospitalized and examined for the possible causes of her temporary sight loss and was also treated for heart failure and respiratory problems, and this small notation followed her during her stay: “86-year-old woman with a glint in her eye.” Even though I was surprised by the liveliness of this woman, an important task for me as a physician was nevertheless to examine her to find a possible reason for her sight loss. Noting only the glint in her eye and not the possible causes of the loss of sight would not have been concordant with proper care. This is an example of how the recording eye is also important for the caring relationship: to care properly is not only to hold the patient’s hand or have a cheerful conversation but also to deliver the proper treatment when needed. As representatives of the medical profession, physicians are of little help if they do not use their trained medical eye during their meetings with patients. Even so, the act of perception helped me to see more of this woman than merely her physical afflictions and shortcomings, and this provided me with an insight about her quality of life that added to the information from her medical journal. Appeal or “appeal”? We may also trace a double eye in the field of psychiatry. In order to grasp the signs and symptoms of depression and to identify depressive thought content, the therapist needs a recording eye. The therapist will be of little help to the patient if he does not recognize these negative patterns of thought but simply empathizes with the patient’s feeling of hopelessness. That the therapist manages to approach the situation with a recording eye, in terms of deciphering the signs and symptoms of a depressive disorder from the totality of a difficult situation, is mandatory in order to reach a diagnosis and offer the right

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treatment. By relieving the patient of feelings of guilt and shame by identifying her feelings of insufficiency and hopelessness as symptoms of depression may also constitute a caring act for the patient. On the other hand, to be open and receptive to the patient’s difficulties and feelings of insufficiency and hopelessness—to be open to receiving some of the patient’s suffering—may provide therapists with insight into the patient’s situation that goes beyond the analytical task of recognizing symptoms and signs. To gain access to the patient’s subjective feeling of distress, the therapist must allow himself to practice perceptual openness to this patient’s suffering. To be perceptually open towards the patient—to be hit in the gut by the patient’s despair—may tell him something about the patient’s level of suffering, which may be relevant to the therapist’s assessment of suicide risk, for instance. Kari Martinsen (1993) points to the patient’s need, expressed as a cry or an appeal for help, and she highlights the importance that health care practitioners “be able to see and express the [patient’s] appeal for help” (p. 9). Interestingly, in psychiatry the term appeal has been used in a different way, conceiving of the patient’s “appealing” behavior as a means of getting attention rather than as an honest cry for help. This is the view of the recording eye, and it may, of course, be useful to recognize such a tendency among patients. However, for patients to be met with the assumption that their cries for help are “appealing” may be damaging, even unethical. From this we see that relying mainly on a recording gaze in meeting with patients may increase the risk of harmful and degrading behavior from the therapist towards the patient. Perceiving during the medical examination The main gaze of the medical examination is a recording gaze. However, the medical examination also provides the practitioner with rich opportunities to display a perceiving attitude toward the patient. What Kari Martinsen writes about attitude, tone, and gesture in nursing care may well be applied to the medical examination, which also gives practitioners opportunities for close contact with patients. The patient often must undress, and the physician has to focus her

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attention on the patient’s body in order to see, feel, and hear. During this close act of focusing on the patient’s body, the physician has an opportunity to get within the perceiving range of life by opening up to the patient’s expressions. By seeing the skin with its different marks, scars, bruises, and rashes, the physician acquires an impression of a lived life and the lived body of the patient. Sometimes, it may be easier to ask for the causes of the bruises when the patient is undressed than to ask during the medical interview, especially if the case involves abuse and violence. The patient’s skin may be flushing red or sweaty, thus revealing anxiety or apprehension. To auscultate the heart and lungs and to measure the blood pressure can, in many cases, be interpreted as a caring act. Such rituals can help patients to feel secure, and physicians can use them as ways of coming closer to the patient. We see from these examples how both the recording and the perceiving approach play roles in the care of the patient. The challenge is thus how to shift between the different ways of seeing patients in actual situations. Here Kari Martinsen turns her attention to clinical judgment as an important mediator. To help the patient, the basic elements of care need to be cultivated by professionals in their clinical judgments, Martinsen argues. The clinical judgment consists both of open and spontaneous receptivity towards the other and of professional consideration: “Clinical judgment in nursing is an interpretative activity, by which professional knowledge and natural perception work together,” she writes (Martinsen, 2003b, p. 145). By this, Martinsen’s (2003a, 2003b) hermeneutical legacy is made visible.

The struggle in the eye In meeting with patients it may be easier and sometimes self-protective for clinicians to deal with the patient’s condition from the perspective of a recording eye rather than to aim to encounter the patient’s suffering. “It is so easy to slide from perceiving to recording,” Kari Martinsen (2006, p. 112) points out, and she describes the task of seeing with a double eye as a struggle that demands an effort from the nurse to focus his participating attention to achieve emotional awareness of the patient. Seeing with the double eye in the medical

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encounter furthermore requires that both patient and physician emerge as persons rather than meeting each other as two distant parties in the third person. It may be easier to slide from perceiving to recording when the therapist distances herself from the patient, hiding behind a “one” or an “undersigned” rather than an “I”. In relation to this, it is interesting to reflect on how physicians write their medical records. The form and style of this documentation leave little room for the experiential data that come from the perceiving eye. The language reflects a recording gaze written in an impersonal manner, as I experienced meeting with the old woman with sight loss: my perception of her differed widely from the medical records written about her. However, in the production of text, there may be a struggle for a way to express what happened during the consultation—for instance, in relation to whether physicians describe themselves as an “I” or a “one,” or even “the undersigned.” I met a surgeon once who said that when she dictated descriptions of operations, she used the “I” form. Most of her colleagues, however, dictated in the third person, using the word “one.” The surgeon added that several of her colleagues criticized her use of the first person, to which she replied, “I’m the one performing the operations, so why can’t I write that?” The desire to dictate using the word “I” rather than “one” might seem like a linguistic detail of little relevance to practice, but the surgeon’s sigh of frustration nonetheless represents more than a triviality of grammar. As I see it, this example illustrates the inherent tension between the personal and the professional in medicine, between “I” and “one.” It may also illustrate the struggle in the eyes that Kari Martinsen describes. In order to be moved emotionally—to be pained in the gut—physicians must present themselves as an “I” in the relation and not as a “one” in the third person.

Seeing enters into person-oriented professionalism These endeavors further the task of developing person-oriented professionalism in medicine and contrast with the traditional understanding of professional interaction. A person-oriented professionalism

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requires professional knowledge that enables one to see the patient as a suffering human being and to protect his integrity. This involves both an openness towards one’s emotions and one’s own affectedness in the clinical encounter and a different approach to the relation between patient and physician: Being professional further entails having professional knowledge which enables one to see the patient as a human being. This means a professional knowledge which does not reduce the other to an object—that is, that the other exists as something we are separated from, and not connected to. … Being professional is also daring to be a human being. (Martinsen, 2006, pp. 74–75)

So, what is the proper mode for being able to do this as a physician? From the previous enquiries in this essay we have seen that it is about presenting oneself as an “I” in the encounter, aiming to display a participating attentiveness towards the patient whereby both the perceiving eye, in terms of seeing with openness and ease, and the recording eye, in terms of academically exploring and evaluating the other, are present at the same time and in friendly interaction with each other, being mediated by clinical judgment. I should point out, however, that this practice does not imply that emotions are always to be given priority over rationality or that patients should be overwhelmed by the physician’s own emotionality. A disclosure of emotions can also be inappropriate on the part of a physician. That is, when the physician’s emotions are exposed primarily in service of the physician himself, it can represent a violation of appropriate boundaries and can give the patient the feeling of not being under appropriate care.

Conclusion Kari Martinsen’s phenomenological ethics of care challenges medicine’s “eye,” in that it calls for the task of seeing to enter into personoriented professionalism. This requires professional knowledge, which enables one to see the patient as a suffering human being and protect her integrity. In this chapter, I have attempted to demonstrate that the two approaches of recording and perceiving do not exclude one

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another. Instead, they can co-exist during the medical examination in what Martinsen calls the double eye, which is as comprehending as it is exploring. This way of seeing is challenging, and it demands effort. It involves a struggle that requires the physician to focus her attentiveness and achieve emotional awareness while meeting with the other. Moreover, this process of seeing depends on the physician and patient emerging as persons in the clinical encounter: as two selves in the first person. When physicians and patients meet each other in the first person, the double eye is strengthened.

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Martinsen, K. (2003a). Omsorg, Sykepleie og Medisin: Historisk-Filosofiske Essays [Care, nursing, and medicine: Historical-philosophical essays] (2nd ed.). Oslo: Universitetsforlaget. Martinsen, K. (2003b). Fra Marx til Løgstrup: Om Etikk og Sanselighet i Sykepleien [From Marx to Løgstrup: On ethics and sensibility in nursing] (2nd ed.). Oslo: Universitetsforlaget. Martinsen, K. (2003c). Fenomenologi og Omsorg [Phenomenology and care] (2nd ed.). Oslo: Universitetsforlaget. Martinsen, K. (2006). Care and Vulnerability. Oslo: Akribe. Nortvedt, P. (2008). Sensibility and Clinical Understanding. Medicine, Health Care and Philosophy, 11, 209–219. Nussbaum, M. C. (1990). Love’s Knowledge: Essays on Philosophy and Literature. New York: Oxford University Press. Pettersen, T. (2008). Comprehending Care: Problems and Possibilities in the Ethics of Care. Plymouth, UK: Lexington Books. Pulcini, E. (2017). What Emotions Motivate Care? Emotion Review, 9(1), 64–71. https://doi.org/10.1177/1754073915615429 Rosen, D. H., & Hoang, U. (2017). Patient-Centered Medicine: A Human Experience. Oxford: Oxford University Press. Stewart, M., Brown, J. B., Weston, W. W., McWhinney, I. R., McWilliam, C. L., & Freeman, T. R.(Eds.). (2003). Patient-Centered Medicine: Transforming the Clinical Method. Oxford: Radcliffe Medical Press. Van Reenen, E., & Van Nistelrooij, I. (2017). A Spoonful of Care Ethics: The Challenges of Enriching Medical Education. Nursing Ethics. https://doi.org/10.1177/ 0969733017747956. Vetlesen, A. J. (1994). Perception, Empathy, and Judgment: An Inquiry into the Preconditions of Moral Performance. University Park, PA: The Pennsylvania State University Press. Zahavi, D. (1999). Self-Awareness and Alterity. Evanston, IL: Northwestern University Press.

Care ethics as relational responsibility An approach by way of Emmanuel Levinas Linus Vanlaere & Roger Burggraeve (KU Leuven)

As Stephanie Collins states in her book The Core of Care Ethics (2015), care ethics is fundamentally a relational ethics. The imperative to enter into and maintain caring relations is central in this ethics. It is claimed that obligations derive from relations between persons. For Collins the slogan “dependency relationships generate responsibilities” encloses the core of care ethics. In this contribution, we try to underbuild the core of care ethics—as formulated by Collins—by refering to the phenomenology of Emmanuel Levinas. His analyses of how our subjectivity is established in the ethical encounter with the Other presents us a detailed vision of precisely what the relational responsibility consists of. Because of the fact that it is precisely the suffering of the other that provokes this responsibility—or responsibility-by-and-for-the-other— we zoom in on this basic theme in Levinas’s phenomenology to sharpen the basic claims of care ethics. Our contribution consists of two parts. In the first part, we present a phenomenology of different forms and modes of suffering. What is so characteristic of suffering that it becomes an ethical appeal? In the second part we focus on the ethical implications of this phenomenology at the “how”, “what” and “why” of the relational responsibility of care.

Care ethics as relational responsbility? We start our contribution with a concrete example of suffering, namely the suffering from cancer of Paul Kalanithi as he bears witness in his book (Kalanithi, 2016). He was practically at the peak of his

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career as a medical specialist when he himself became seriously ill. From his hospital bed—which also became his deathbed—he wrote down autobiographical notes that later were compiled into a book entitled When Breath Becomes Air. Thanks to this book, we get a unique glimpse into the thoughts and feelings of a young, ambitious neurosurgeon who (also) became a patient. From his notes, we come to understand what the experience of being a care-receiver does to his being a care-giver. One of his reflections goes as follows: Doctors in highly charged fields with patients at inflected moments, the most authentic moments, where life and identity were under threat; their duty included learning what made--- that particular patient’s life worth living, and planning to save those things if possible—or to allow the peace of death if not. Such power required deep responsibility, sharing in guilt and recrimination. (Kalanithi, 2016, p. 113)

All those active as care-givers will recognise themselves (partly) in Kalanithi’s writing. Whatever professionalism or speciality you possess, in whatever domain your activities may be situated, the core of care always revolves around the suffering of the patient, a suffering that threatens the life or the identity of the one suffering, or puts them seriously under pressure. Why you do what you do as a caregiver, and likewise how you do it, harks back for many care-givers to the suffering of the other that moves them and appeals to them. What Kalanithi articulates as his “task” or “mission” is without doubt applicable too to many care-givers. Their responsibility is rooted in the suffering of the other. Care ethics (a specific form of ethics of care) unfolds itself as an ethics of relational responsibility. The normative element of care ethics is often the subject of discussion. The Levinasian concept of responsibility-by-and-for-the-other seems to us the most suitable for providing a basis for the care for people who suffer (Benaroyo, 2017, p. 29). In his book, Paul Kalanithi reveals that he initially thought he “knew” how people who were entrusted to his care were suffering. He thus thought he understood what his responsibility and care likewise consisted of. Through the process of his own illness and through

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experiencing care as the recipient, he arrives at the insight that suffering can never be understood entirely. And precisely that aspect brings along with it an exceptional responsibility. Throughout our investigation, it will become clear how the initial timidity with which care ethicists talk about suffering simply increases. Just like Kalanithi, we discover that it is indeed not about a “problem” that we, as philosophers, can situate outside ourselves in order to dissect and understand it as it were from a distance, in a neutral manner. Rather, we encounter a “mystery” of which we ourselves partake and in which we ourselves participate involuntarily (Marcel, 1951). We are not outsiders but complete insiders, not only because, sooner or later, we all undergo suffering, but because it is an essential dimension of human existence. This awareness is essential for care ethics. The ethics for which care ethics stands can never be separated from one’s own life. Moreover, suffering—even our own suffering— can never be entirely “grasped.” At the same time, this (last) awareness implies that the forms and modes of experience of suffering that we now attempt to describe never coincide with the concrete experiences of people. Although we all share a common humanity, and suffering and vulnerability are aspects of the human condition, there is an essence of non-comprehension in trying to understand the other person. Apart from the fact that we cannot fully understand the experiences of the other, it is also important to emphasize that we only have an insufficient approximating identification with the other through care as reponsbility, as we will explain further.

A phenomenology of suffering What is immediately noticeable is that the one word, “suffering,” is used to indicate so many different things: pain, sorrow, misery, evil, unhappiness… Moreover, suffering often refers to a tangle of wretchedness. Unravelling this tangle is almost impossible; suffering is a complex human experience. Every attempt at disentangling it bears within it the risk of reducing that experience or even aestheticizing it. Bearing in mind this risk, we shall nonetheless try to explain some forms of suffering.

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Affected by what people own: economic suffering When we talk about suffering, we often refer immediately to bodily suffering. Yet we would like to reflect first on a no less real and tangible form of suffering, namely the so-called “economic suffering.” We sketch this form of suffering first because having a good grasp of it will help us to better sense and evoke the mystery of bodily suffering. Put succinctly, we can describe economic suffering as being affected in one’s possessions, not only material things, but also ideas, creative designs, writings, a job, a career … We thereby find ourselves on the level of what remains external to us: we arrogate that which is not ourselves. By means of arrogation, it only becomes “of ourselves” and not ourselves. And yet precisely in the arrogation it becomes a part of ourselves, and we become attached to it. A passionate bond with our possessions can even lead to a possession becoming part of our identity. That is why being affected by what one owns can also affect who someone is. An example of that is Kalanithi himself, a brilliant specialist-in-the-making: because of his illness, he loses the chance to take up an academic position in Stanford, and this affects who he is. A local meeting of former Stanford neurosurgery graduates was happening that weekend, and I looked forward to the chance to reconnect with my former self. Yet being there merely heightened the surreal contrast of what my life was now. I was surrounded by success and possibility and ambition, by peers and seniors whose lives were running along a trajectory that was no longer mine, whose bodies could still tolerate standing for a gruelling, eight-hour surgery.... My senior peers were living the future that was no longer mine: early career awards, promotions, new houses. … a paralytic uncertainty loomed: Who would I be, going forward, and for how long? (Kalanithi, 2016, pp. 146-147)

Kalanithi not only loses something (career opportunity, prizes, promotions …), he also feels himself lost and stricken. After all, he has invested all his energy, knowledge and ability to substantiate his “business” so that it has not only become his business, but a certain identification with his business has taken place. He feels affected in his self.

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Undoubtedly for Kalanithi, the loss feels like a failure: he is affected in his “attempt-at-being,” namely in his attempt to develop and give shape to his existence. It is no coincidence that this self-development is economic in nature. As bodily and fragile beings, we are in search of the satisfaction of our very concrete, earthly and material necessities. On the basis of this neediness, we are a self-interested attempt-atbeing, literally an “attempt in order to be” (Levinas, 1981, pp.  4-5). That attempt encompasses precisely how Joan Tronto defines care, namely as “all that we do to let the world continue in existence, to restore it, and to maintain it, so that it becomes ‘our’ world wherein we can live as well as possible” (Tronto, 1993, p. 162). The term “economics” must therefore be understood in the broad sense as the processing and arrangement of the world into a home for ourselves. And since this economic relationship to the world is never completed, our attempt-at-being remains fragile and assailable, which connects it directly to the phenomenon of failure as a form of suffering. Failure reveals to me how I fall short with respect to my own attempt-at-being. This is what Ricoeur calls échec, which is not an ethical category like fault (Ricoeur 2001). I turn out not capable of giving an answer to what is expected of me, which forms a daily, painful experience. If I “fail” through my own doing, then I can “remedy” the situation: I had better do my best, see to it that I set before me more achievable goals or I can patiently postpone for later what cannot yet (entirely) be done today. But if I “fail” because of what fate has dealt me as in the case of Kalanithi, then I stand more powerless. Kalanithi feels paralysed because he does not possess the possibilities to remedy the situation and come out stronger. He feels estranged because he is deprived of “him-self” and his capabilities. Affected in what one is: bodily suffering At the same time, for Kalanithi the situation is neither fatal nor final: what he could achieve before is no longer within reach, neither in the long term, but there are alternatives available that are, to be sure, not equally valuable but still valid—at least if his abilities are not further affected by the cancer he suffers from. If that remains under

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control and he can overcome it, then he is able to rationalise and relativize his losses. He is able to hold his head up high. In contrast, bodily suffering displays an unambiguous fatality. Bodily suffering affects me not in my “externality,” in my possessions, but directly in my own being. It cannot be relativized. It is practically impossible to distance oneself from it or to rationalize it. Moreover, it eludes entirely my control, ability and initiative. In bodily suffering, my possibilities and powers themselves are affected so that an even more fatal sense of passivity arises than in economic suffering (Levinas, 1987a, p.  69). During the physiotherapy Kalanithi has to undergo in his revalidation, he writes: This was exhausting and humiliating. My brain was fine, but I did not feel like myself. My body was frail and weak—the person who could run half marathons was a distant memory—and that, too, shapes your identity. Racking back pain can mould an identity; fatigue and nausea can, as well. (Kalanithi, 2016, p. 140)

Even when he thinks he has been revalidated sufficiently to again work as a surgeon in a hospital, he experiences how the constant presence of pain undermines everything. I ended my days exhausted beyond measure, muscles on fire, slowly improving. But the truth was, it was joyless. The visceral pleasure I’d once found in operating was gone, replaced by an iron focus on overcoming the nausea, the pain, the fatigue. (Kalanithi, 2016, p. 156)

Kalanithi experiences his bodily suffering as an act of violence: he feels being seized and overwhelmed by the other. He is, as it were, crushed in himself, paralyzed, degraded into an object (Levinas, 1979, pp. 164165). The entire acuteness of bodily suffering consists in its being without recourse: I find myself in the impossibility to escape, the inability to protect myself against myself. I am incapable of commanding or forcing the bodily pain to go away (Levinas, 2006a, p. 78). Bodily suffering is usually coupled with pain, and yet pain is not always the indication of suffering. Acutely intense pain can be a source of bodily suffering, but chronic pain that is less intense likewise causes serious bodily suffering. Just think of chronic, recurring

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pain that embitters daily life like clockwork, and that often can acerbate character. Or think of handicaps that can mess up one’s life from one day to the other. Or of diseases that confront people with certain or impending death. And not to mention the process of ageing, when the body wherein one feels at home starts letting one down. The maladies that ensue from it impair not only our bodily but also our emotional and mental capabilities. Pain affects us in our totality and openness to the world and in how we experience existence. For a person in chronic pain, our ordinarily unproblematic attitude to the world becomes problematic. It affects concentration, and because a person in pain has to concentrate on concentrating, it becomes a double endeavour. It affects sleep and our relationships to others. Some patients bear witness of the fact that they are so taken by their own suffering that to see this suffering in the eyes of beloved ones, is really too much. Pain in some sense decreases human sensibilities, we are more and more shut up in our own world and coping. The ordinary flow of impressions, the human receptivity and sensibility is broken. In bodily suffering, death acquires an exceptional actuality. While death in fact remains future-orientated in its threat, bodily suffering sees to it that this threat becomes actual (Levinas, 1998, pp. 127-128). Thus Kalanithi (2016) says: Before my cancer was diagnosed, I knew that someday I would die, but I  didn’t know when. After the diagnosis, I knew that someday I would die, but I didn’t know when. But now I knew it acutely. (p. 132)

With the actuality of death likewise comes an immeasurable fear. Fear of death and bodily suffering are strongly intertwined. We find that as well in Kalanithi, who thought he knew death through his daily practice as a doctor who had to decide in matters of life and death, but who now experiences immense fear due to his own sickness and bodily suffering. I’d always imagined the doctor’s work as something like connecting two pieces of railroad track, allowing a smooth journey for the patient. I hadn’t expected the prospect of facing my own mortality to be so disorienting, so dislocating. (Kalanithi, 2016, p. 148)

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In bodily suffering, fear is not a mental disorder but it is indeed something corporeal. It is the sharp point itself of bodily suffering. The serious disease, the metastasizing malady in the living but at the same time degenerating body, the decay and unavoidable decline: those are the modalities themselves of fear. By means of these modalities, death is now already present in our flesh, real and active, as threatening mortality. Death can no longer be denied. Bodily suffering thus reveals our utter vulnerability. Just as Kalanithi describes in all accuracy, it likewise affects our identity. The hopelessness and fear that death brings along with it has nothing to do with a kind of spirituality of a tragic knowing. They occur as mal de chair or “suffering in the flesh.” Bodily suffering is the very depth of the fear of despair (Levinas, 1987a, p. 72). Affected by mental suffering As a human experience, suffering always has a direct impact on the emotional side of the subject whereby every suffering—even the most bodily affliction—is a mental form of suffering. We see that in Kalanithi: his bodily suffering ends up in the feeling of self-alienation. Intense or acute suffering violates the person in one’s intimacy with one’s self. A sick person does not only feel struck down by the illness but also assaulted. Kalanithi, for instance, feels literally “stripped,” alienated from himself. Mental suffering presents itself in all sorts of forms and combinations that, for the outside world, are often quite incomprehensible. Since it is easier to point to the cause of bodily illness, one has less of a problem with it in general. Mental difficulties surprise us not only because of their multiformity, but also through their diverse intensities, depths and whether they are reversible or not. Aside from the shame of the sick person, due to the taboo surrounding mental illness that still prevails in society, more often than not the sick person gets isolated because one’s immediate surroundings at times gets tired and despondent in its not-being-able-to-understand. Not infrequently, mental suffering also affects the ability for selfdetermination. The sick person does not succeed in standing at the

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helm of one’s life. That as well is part of the disease. But even here, the outside world does not always react with understanding—“Come out of it! Do something about it!”—which makes the sick person even more trapped in inability and isolation. By means of ending up in negative spiral, mental suffering can become a dead-end: the sick person, or the surroundings, can no longer find any chance/opportunity to give meaning to life. Just as bodily suffering often brings about mental suffering, the reverse is also possible: mental suffering at times has a bodily impact. Mental suffering leaves its marks on the somatic in the sense that emotionally deep and radical mental maladies can transform into certain somatic diseases. Relational and social suffering Aside from bodily and mental suffering, we likewise have relational and social suffering—and these are not to be underestimated. This kind of suffering exists in many forms. Here we shall only sketch a few of those forms that are the result of bodily and mental suffering. That bodily illness has an impact on interpersonal relationships is already indicated by Kalanithi when he writes about his contact with his classmates at university: he looks at them with different eyes, they regard him in another way. He is no longer part of the group. He is aware of it and this isolates him even more. But also his relationship with his partner Lucy and his family changes… My family engaged in a flurry of activity to transform my life from that of a doctor to that of a patient. We set up an account with a mail-order pharmacy, ordered a bed rail, and bought an ergonomic mattress to help alleviate the searing back pain. Our financial plan, which a few days before had banked on my income increasing six-fold in the next year, now looked precarious, and a variety of new financial instruments seemed necessary to protect Lucy. My father declared that these modifications were capitulations to the disease: I was going to beat this thing, I would somehow be cured. How often had I heard a patient’s family member make similar declarations? I never knew what to say to them then, and I didn’t know what to say to my father now. (Kalanithi, 2016, pp. 126-127)

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Much more is contained in this passage than what is described above. It is remarkable how Kalanithi implicitly refers to the suffering that is contained in the change of roles from caregiver to care-receiver, from a brilliant son starting out his bright career to a sick son who needs care. It confirms him even more in his position as a powerless, helpless failure. With the prospect of impending death, he chooses with his partner Lucy to conceive a child even though the awareness of the consequences of this choice—namely that the baby daughter that was eventually born to them will have to grow up without a father—also ushered in suffering. At the moment that his wife was giving birth, Kalanithi lay beside her in his hospital bed, with bed-warmers and blankets to prevent his skeletal body from shivering due to the cold. The impact of new life over and against his declining life is immense. Another form of interpersonal suffering, of which Kalanithi also makes mention, is the social misery that flows forth from bodily suffering. In his bodily appearance of becoming ugly, decline, sickness, suffering literally becomes “offensive.” It offends the outsider and involuntarily isolates the one suffering: many of us would rather not be involved, we would rather look the other way. Suffering is the root of abandonment and loneliness. For instance, Kalanithi writes of how with the intake of a specific medicine he develops severe acne. His previously smooth complexion is now riddled with pimples that constantly bleed due to the blood-diluters that he would also take. Although he does not write much more about it, we can imagine that the awareness of being much less attractive is the reason for mingling less with people. Just like an elderly woman with Parkinson’s, who because of the condition makes a mess while having a meal, decides because of shame no longer to eat in the dining room of the care centre and ends up all the lonelier. No longer knowing how to deal with sick people, and the unease that results from this, might have the consequence that sick people are all the more isolated. It then is quite difficult, if not impossible, to get through to the inner confusion and affectedness that suffering brings about in the mood of sick persons. One’s own suffering is

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experienced as utterly unique and un-shareable. That sick persons intend to “spare” their immediate surroundings, and vice-versa, piles suffering upon suffering (Levinas, 2006a, pp. 78-79). Relational and social suffering thus often do not stand on their own. They are intertwined with another form of suffering, be it as cause or as consequence. Often, mental suffering is a consequence of relational and social problems. At the same time, bodily suffering also usually brings forth forms of relational and even social suffering. The story of Kalanithi makes clear in any case that bodily suffering also brings about mental suffering, and even makes its impact on the relational and social field. The latter then reinforces mental suffering and can even end up in a form of hopelessness. Ethical suffering A specific form of relational and social suffering is ethical suffering, meaning to say the suffering that flows forth from exclusion, domination, abuse, humiliation—in short, all sorts of injustice. Ethical suffering ensues from being unseen and unacknowledged as a person with your own value and identity. Suffering people are even more defenceless and can end up in situations wherein suffering is heaped upon their suffering (van Heijst, 2011). Kalanithi experiences that as well when he is brought to the emergency unit due to extreme nausea and dehydration as a result of chemotherapy. Although he himself is a doctor, the examining doctor at the emergency unit—who is called Brad—decides unilaterally to stop a certain medication. Kalanithi tries to oppose the decision, but is left unheard. He feels miserable and realises that as the patient he has no say in this matter. He feels slighted and reduced to an object: I could see that in Brad’s eyes I was not a patient, I was a problem: a box to be checked off (Kalanithi, 2016, p. 187)

Inadvertently, he had to think of what a patient once confided to him: that she always wore her most expensive hosiery whenever she had a doctor’s appointment so that the doctor, when she would be garbed in the hospital gown without her shoes, would see the hosiery

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and would know that she wasn’t just anybody and had to be treated with respect. Suffering due to moral guilt is also ethical suffering. As regards moral guilt, we must point out the fact that falling short of our responsibility—whether it involves ourselves or others—brings about a subjective form of pain and suffering, namely the feelings of guilt, shame and remorse. Yet here, however, we must distinguish between a positive and a negative form of suffering. On the one hand, guilt feeling, which causes unease and pain in our conscience, is a sign that we are human. Conscience, after all, is the scruple in our attempt-atbeing, namely the unease about the brutality of our struggle for life that while being left to itself considers nothing or no one unless when one’s own being and self-interest is at stake. This conscience is salutary since it puts us on the trail to human dignity, in the sense that it lifts us above our attempt-at-being towards the other than ourselves. People without guilt feelings become inhumane persons. Hence it is not advisable to exonerate people of all guilt or literally to “exculpate” them, making use of the (human) sciences that (are able to) lay bare all sorts of factors that condition behaviour. Deculpabilisation can be useful and necessary in order to exonerate people who are not or only partially accountable, but it should never end up in a general “de-ethicisation” meaning to say in the elimination of free and responsible will. By doing so, the human individual loses their distinctive human dignity. This emphasis on the humanising significance of guilt and the awareness of guilt does not preclude other forms of guilt awareness that are destructive in nature. The guilt feeling, for instance, can be so deeply nestled in the mind that the person in question is utterly crushed by it so that he is equated with his past and thus no longer sees any future and perspective for growth. Or people can be so deeply burdened by an unresolved guilt towards another (parent, child, partner, friend) that they are drawn backwards into a never-ending infantile regression, precisely in order to escape from the guilt that presupposes a certain maturity and adulthood. When people get stuck in their guilt as a consequence of all sorts of experiences, they end up here and now in a “hell” that

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immerses their existence in the “sickness unto death,” as the Danish philosopher Kierkegaard calls this desperation. The outcome of this destructive moral guilt sets us on the tracks of suffering due to existential meaninglessness. And so we come to what we can call “spiritual suffering.” Spiritual suffering In spiritual suffering, we actually distinguish two forms, namely moral guilt and existential meaninglessness. Here, we shall only discuss the latter form. When bodily, mental, inter-personal and social suffering—separately or (often) in combination—become a prolonged and intense ordeal, the temptation to despair is never far behind. We also read this in Kalanithi (2016), even at the beginning of his disease. I was physically debilitated, my imagined future and my personal identity collapsed, and I faced the same existential quandaries my patients faced. The lung cancer diagnosis was confirmed. My carefully planned and hardwon future no longer existed. Death, so familiar to me in my work, was now paying a personal visit. Here we were, finally face-to-face, and yet nothing about it seemed recognizable. Standing at the crossroads where I should have been able to see and follow the footprints of the countless patients I had treated over the years, I saw instead only a blank, a harsh, vacant, gleaming, white desert, as if a sandstorm had erased all trace of familiarity. (pp. 120-121)

Slowly but surely, resistance and fortitude become affected until one ends up in doubt and is inclined to lower one’s defences. In such moments of doubt there is no sense anymore in fighting against the suffering; even life itself loses its meaning. The fundamental trust is affected and slips like sand through one’s fingers. The reasons for living seem affected in their core. There is no possibility anymore to give one or the other meaning: the path to finding meaning has been cut off. The suffering that one has to bear leads nowhere; it is “useless” (Levinas, 2006a, pp. 79-80). This meaninglessness does not only arise in the context of bodily and mental illness, but also when suffering brutally breaks into one’s existence and throws off-balance that once happy and (sufficiently)

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balanced life. Think of the loss of a partner due to a sudden death, or of a child after an accident, or the birth of a sick or handicapped child. In that moment, everything becomes chaos and “repugnant.” A bitter feeling of absurdity raises its ugly head. A feeling that resembles greatly what Jean-Paul Sartre, in the line with Levinas, calls disgust (“la nausée”). One’s own existence is experienced as too much and the suffering person wants to escape from him- or herself and their own existence, even though it is not possible (Levinas, 2003, pp. 66-68). Even when existential suffering does not (immediately) lead to a feeling of absurdity, it expresses itself in other ways. As for instance through the phenomenon of boredom. In his “carnet spirituel”, Xavier Thévenot (1987) witnesses boredom and how deeply it seeps in: time that becomes monotonous and daily existence that drags on and on without any relief, through which life presents itself as death (p. 43). Kalanithi also testifies to that in his book, as the super-active doctor who due to illness suddenly turns into a patient that becomes the object of his “life without life.” The image of the desert that he uses in the quote above is not at all coincidental. It illustrates the radical hopelessness and the absolute absurdity of existence. Moreover, this feeling of absurdity affects not only existence here and now, but it also undermines the past. What up to that point was a source of joy, now becomes a source of suffering. Just think of Kalanithi’s words on the deeply-rooted pleasure he had when he operated, which now has become joyless due to the focus on surviving. When he is able to work briefly again, he feels, thanks to the renewed contact with his patients, how work accorded him meaning, but at the same time he experiences how it will never be just like it was before. Useless suffering All this leads Levinas to label suffering, beyond all its forms and dimensions, as the excessive par excellence. The term “excessive,” however, should not be understood quantitatively, thus not in the sense of intensity that goes beyond a certain degree or measure. Suffering is not disproportionate because it can be so strong and tumultuous that it goes

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beyond the bearable, even though we most easily come to be aware of its excessiveness through its intensity. Evil is disproportion in essence. In other words, we need to understand the excessiveness of suffering qualitatively, namely as a break with the normal and normative, with what is obvious or what corresponds to one’s expectations, as a violation of the order, the syn-thesis, the regulated, the fitting, in short as the frustration of all that agrees with the attempt-at-being and fits with the dynamics of the personal project-of-existence. Suffering is essentially and literally ex-cessive: it overflows the banks of healthy selfunfolding. It essentially runs counter to the power of self-determination (Levinas, 1994, pp. 131-132). That is also why Levinas calls suffering “the unassumable” (Levinas, 2006a, p. 78): that which we attempt to appropriate to ourselves and take up as a part of our design-for-existence, but which escapes us time and again. Suffering repeatedly disarms us, even though we try time and again to grab these weapons back. But even that fails. And it is this infernal downward spiral of failure that establishes the evilness of suffering. Ultimately it allows no synthesis or order, even though there seems to be temporarily some order now and then. Suffering is a filthy alterity, an indigestible heterogeneity and disparity. Suffering is essentially the refusal itself of all synthesis, even though we are for the moment—or even for a longer period—lulled into sleep by recovery: “at once what disturbs order and this disturbance itself” (Levinas, 2006a, p. 79). And this radical opposition is no formal or intellectual heteronomy but a contradiction as well as perception: the painfulness of pain, be it physical, psychic, psychosomatic, social or spiritual pain; unbearable and unacceptable evil, that submerges us into passivity. It is, in other words, suffering as “experience,” not to be understood as act but as even “despite ourselves.” The passivity of suffering that affects us is much more radically passive than the receptivity of our senses that still exhibit an active passivity, meaning to say an intentional receptiveness, which then takes place as perception. In suffering, sensibility is a vulnerability, more passive than receptivity. It is precisely an evil. It is not, to tell the truth, through

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passivity that evil is described, but through evil that suffering is understood. Suffering is a pure undergoing (Levinas, 2006a, p. 79). And the pain of every kind of suffering is the expression and the realisation itself thereof, including the intense pain that swallows up consciousness entirely and reduces it to (almost) nothing. In the hellish pain, the wild evilness of suffering shows itself. And as evil suffering “is the impasse of life and of being—their absurdity”: “for nothing,” “useless,” “the depth of meaninglessness,” “the evil of pain, the deleterious per se, is the outburst and deepest expression, so to speak, of absurdity” (Levinas, 2006a, p. 79).

The suffering of the other as ethical appeal for responsible care Let us return to the starting point of this article: the how, what and why of care and the responsibility for the other. That responsibility stands in relation to the suffering of the other, at least this is how Kalanithi sees it. Care ethics, as an ethics of responsibility, takes its starting point in the vulnerability and the concrete being-injured of the other. That was the reason for taking the time to reflect on the forms and modes of experience of suffering. Obviously much more can be said in that regard. At the same time, and with Kalanithi, we can state: doctors and caregivers understand so little of the hell and of the entanglement of suffering that patients endure (Kalanithi, 2016, p. 127). This is not out of unwillingness or indifference—which can also be, as we shall see—but rather out of suffering itself which even for the one suffering is up to a certain extent inaccessible. This observation leads to a special ethical dynamism, as we will now indicate with Levinas. In order to start this reflection with the very experiences themselves, let us first return to Kalanithi. Kalanithi’s “tempering” In undergoing his own processes of becoming ill and of suffering, he experiences how his assigned doctor and colleague, Doctor Emma, takes up responsibility for him in an exceptional manner. At a given moment, he writes that his doctor had come to protect his ability to create a new identity in light of his illness. She kept an eye on the

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part of his identity that was so important for him to be “him-self”. He writes: [Doctor Emma] had done what I had challenged myself to do as a doctor years earlier: accepted mortal responsibility for my soul and returned me to a point where I could return to myself. (Kalanithi, 2016, pp. 163-164)

His own process and the experience of how his doctor relates to him has in fact taught him what could not be learned from Hippocrates, Maimonides or Osler, namely: The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence. (Kalanithi, 2016, p. 166)

Prompted by his own experience of being-sick and receiving care, Kalanithi gains more awareness of suffering in its many forms and facets; he understands the tangle of misery that is suffering, or rather, he understands at the same time that the suffering of the other can never (entirely) be understood. As a physician, he thereby does not become less responsible; his responsibility takes on another colour and dimension, it becomes to a certain extent even “greater.” To (better) understand this, we turn back to Levinas. For Levinas, it is actually such that precisely in the evil of the suffering of the vulnerable and injured other, an appeal breaks through that is addressed to me and calls me to “assist,” to help and care (Levinas, 2006a, p. 80). Here we encounter the ethical dynamism which lies interwoven in suffering itself. In three strong convergent texts, namely the article “La souffrance inutile” (1982) [Useless suffering] and the interviews “L’éthique est transcendance” (1990) [Ethics and transcendence] and “Une éthique de la souffrance” (1994) [An ethics of suffering], Levinas describes how suffering is the concrete way in which the ethical appeal to responsibility presents itself before me, provoking me. Ethical foundation of care for the suffering other The suffering of the other—which is never general nor abstract, not even my suffering but always her [his] suffering—externalises itself not

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only in pain but also in a “cry for help”. This cry expresses itself in fundamental forms of non-verbal language, for instance in weeping, in moaning or in mourning. At times, it expresses itself in a wordless silence during moments that the hopelessness of suffering becomes incomprehensible (Levinas, 1994, pp.  131-132). We see this in the fragment wherein Kalanithi describes how Doctor Emma finds no way out and looks for ways to convey this to him without offending or demoralizing him. In the silence, the (mutual) cry for help (“Don’t leave me alone—Don’t let me go”) is revealed as well as concealed. It indeed is—as Kalanithi describes it—“almost a prayer” (Levinas, 1994, p. 133). Suffering is no pure subjective experience of a solipsistic monad closed-in on itself without doors and windows (Leibniz). On the contrary, in the malignance of suffering, what manifests itself is not only the pain (that throws the one suffering back to oneself), but likewise an openness which is opened up outwards as a cry, addressed to someone else. It is addressed to me, and its alterity or externality implies a promise of wholeness (healing). In this regard, a sign of sociality, a glimpse of meaning, emerges in the pain. In unbearable pain, the transcendence of the interpersonal becomes apparent, its specific and eminent incarnations being the concrete forms of medical treatment and professional care (Levinas, 1990, p. 81). Suffering thus includes a remarkable paradox. On the one hand, it throws the person back entirely to itself, it locks one shut in one’s own body and one’s own self, and suffering then is “an experience of the passivity of the subject” (Levinas, 1987a, p.  70). On the other hand, in this confinement to oneself a notable breakthrough takes place: considering there is no wholeness in oneself, the one suffering cannot but make an appeal to the other person. This appeal of the suffering of someone else arouses and inspires me to care. It is the helplessness of the suffering other that cries out not to abandon the other (Levinas, 1990, pp.  43-44). This means that it is the face of the suffering Other that appeals to me, regardless of the intentionality of the sufferer as subject. The ethical appeal of suffering is not merely a result of the intertional efforts of the suffering Other, but

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it is also intrinsically how suffering expresses itself to the world, as an ethical appeal, to care, and alleviate. The latter is not only the inspiration for all care, but also for nursing and medicine: the medical-nursing profession is primordially and irreducibly ethical. It is precisely on the basis of the appeal that ensues from the suffering of the other that the medical and nursing professions must develop themselves into medical science and into technical practice. All medical and nursing techniques have an ethical foundation and are able—should be able—to become the expression of the responsible care for the suffering other. In other words, the norm of medicine and nursing is the life and well-being of the other, for which one takes up responsibility unconditionally not because one likes it but because one is called and summoned to it. The suffering of the other is after all so unacceptable that it calls to “attention and action”—not in a noncommittal but in an immediately peremptory and almost obtrusive manner—to do something to remedy that suffering, without delay (Levinas, 2006a, pp. 80-81). Temptation to indifference Something remarkable is at hand, however, with this ethical appeal. On the part of the one who hears or notices the appeal, there is indeed no automatic pairing with a spontaneous, evident and naturally swelling enthusiasm. Rather it is coupled with a certain counterwill and resistance, meaning to say with an inclination to reject the appeal. To assess the ethical appeal adequately and realistically, we must therefore first reflect on this resistance and counter-will. We shall do so on the basis of an incident that Kalanithi (2016) describes in his book. A thirty-five-year-old sat in her ICU bed, a sheen of terror on her face. She had been shopping for her sister’s birthday when she’d had a seizure. A scan showed that a benign brain tumour was pressing on her right frontal lobe. In terms of operative risk, it was the best kind of tumour to have, and the best place to have it; surgery would almost certainly eliminate her seizures. The alternative was a lifetime on toxic anti-seizure

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medications. But I could see that the idea of brain surgery terrified her, more than most. She was lonesome and in a strange place, having been swept out of the familiar hubbub of a shopping mall and into the alien beeps and alarms and antiseptic smells of an ICU. (p. 89-90)

With his observation of this woman, an observation that clearly surpasses clinical diagnosis, Kalanithi makes known that he notices the suffering of this woman. This is clearly about an involved observation: an observation wherein he lets himself be involved as a person, wherein he is or becomes included in that which is being observed. This is the appeal of which Levinas speaks. Kalanithi cannot not see it. He can pretend he has not seen it, that he can do. And that is also the temptation that presents itself before him. She would likely refuse surgery if I launched into a detached spiel detailing all the risks and possible complications. I could do so, document her refusal in the chart, consider my duty discharged, and move on to the next task. (Kalanithi, 2016, p. 90)

In the pages that come before and after this account, Kalanithi mentions how a doctor-in-residency-training easily becomes overworked in the practice and how fast one becomes preoccupied with empty formalism, directed entirely towards the mechanical treatment of diseases—and utterly overlooking its deeper significance for the human person. Kalanithi refers by this to the fact that the health care system is not organized in such a manner as to really cope with fragmentation and reductionism. What characterises much of health care, at least part of it, is forgetfulness of the subject and subjectivity. What Kalanithi here really elucidates, which is a genuine Levinasian insight, is subjectivity; how illness impairs the self and affects subjectivity, subjectivity understood as the subject’s personal experiences. But even if it is sometimes acceptable to direct yourself, as physician, directly towards the mechanical treatment of the disease, and that even patients can expect this, this is not the same as to pretend not to notice the suffering of the other and formally close off the case. In the case of Kalanithi, he can likewise pretend that he has not noticed the suffering of this woman

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and formally close off the case, basing himself on the refusal by the patient. But he comes to a decision. [Instead] with her permission, I gathered her family with her, and together, we calmly talked through the options. As we talked, I could see the enormousness of the choice she faced dwindle into a difficult but understandable decision. I had met her in a space where she was a person, instead of a problem to be solved. She chose surgery. The operation went smoothly. She went home two days later, and never seized again. (Kalanithi, 2016, p. 90)

Levinas teaches us that the suffering of the other turns my attemptat-being, meaning to say my project of existence and self-development, upside-down. Moved by my own attempt-at-being, I would rather not like to be confronted with the suffering of the other (Levinas, 1994, p.  135). Even for a doctor-assistant like Kalanithi, one learns quickly how to survive by mainly focusing on the mechanical symptoms and the medical treatment of diseases and disregarding completely its underlying meaning for the person: But in residency, something else was gradually unfolding. In the midst of this endless barrage of head injuries, I began to suspect that being so close to the fiery light of such moments only blinded me to their nature, like trying to learn astronomy by staring directly at the sun. I was not yet with patients in their pivotal moments, I was merely at those pivotal moments. I observed a lot of suffering; worse, I became inured to it. Drowning, even in blood, one adapts, learns to float, to swim, even to enjoy life, bonding with the nurses, doctors, and others who are clinging to the same raft, caught in the same tide. (Kalanithi, 2016, pp. 81-82).

Levinas points out that giving in to the temptation to indifference—namely not to see the suffering of the other, the significance of the suffering of the other for oneself—is in fact a temptation to murder (Levinas, 1985, p.  86). The suffering of the other disturbs and disrupts us, it throws us off-balance, disrupts our agenda, invades our emotional world and disturbs our mood, whereby we lose our equanimity. We no longer have everything under control. The suffering of the other is the concrete, poignant heteronomy of the other that breaks into our existence unannounced and unabashed.

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On the basis of our own insight and capabilities, we do not know what to do about it. Avoiding the suffering other is thus a natural reflex. It is not an expression of a perverse, diabolical or sadistic personality. Such a reflex is normal. The suffering of the other is not only unexpected, but also utterly undesired and counter-natural, literally a contresens, an aversion. To try to escape that is precisely the “temptation (and attempt) to kill”. To kill must be understood here as reducing the other to their appearance or their diagnosis (Levinas, 1979, p. 199). As Kalanithi declares: neatly diagnosing the suffering, but not seeing (or not wanting to see) its significance. It is “reducing the other to myself”, as a mere means or object of medical practice. To kill can also take place by means of crushing or excluding the other, namely by considering the other as a “foreign other” who does not belong with me and has no rights: racism in whichever shape or form (Levinas, 2001, pp. 110-111). To kill can also be much more subtle, namely as “warily walking on by”: to pretend that nothing has happened. To kill as to forget, to disregard, inattentiveness… including all forms of rhetoric and misleading justifications (whether or not professional or medical-scientific) (Levinas, 1979, pp. 70-72). Levinas points out how it costs us little effort, out of our attemptat-being, to neglect, to avoid or to ignore the other as other (Levinas, 1999a, pp. 104-105). The face of the suffering other as an ethical appeal: “Do not kill!” Precisely in the temptation to “kill” the other, i.e. to neglect or to crush the other, or to rid the other of their unique otherness, lies the ethical meaning of the face according to Levinas. The ethical dynamism lies interwoven in suffering itself, in the sense that the suffering of the other is a “source of responsibility” (Levinas, 1994, p. 133). During her internship, a nursing student is confronted with an older patient with dementia. While administering hygiene care, the patient loses control of bodily functions. Precisely at the moment of disgust when she briefly considered walking away, the student

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becomes aware that she cannot walk away without making the situation even worse than it already is for the patient. Thus at the moment that she is confronted with the naked face or the vulnerability of the other and is considering leaving the other to its fate, she becomes aware that what she can do she actually should not do. That is the core of the fundamental ethical experience that proceeds from the face of the other, namely the prohibition against abandoning the other. Levinas expresses this as a categorical imperative that flows forth from the face: “You shall not kill.” In my complacent attempt-at-being, not only am I restricted from the outside but I am from deep within—in my very own freedom—likewise shocked and questioned. Here we encounter the lower boundary of ethics, namely the minimal condition for humane, interpersonal relationships (Levinas, 1979, p. 82). Levinas also emphasises that the face of the suffering other as prohibition cannot enforce anything, but only call and request, can only oblige by means of begging. The face is a “disarming authority” that can only make a claim on me by appealing to my free, good will. I  can toss this appeal to the winds — by free will. The face of the suffering other means for me the experience of violence (in its hard or soft forms) as permanent conversion and real possibility, and therein the immediate awareness that I should not be the murderer of the other (Levinas, 1979, pp. 83-84). Of this violence, Kalanithi testifies to his vulnerability as well. Not only about the violence that is done to him as patient, but also about the violence that he as a doctor has done to others. For instance: A mother came to me, newly diagnosed with brain cancer. She was confused, scared, overcome by uncertainty. I was exhausted, disconnected. I rushed through her questions, assured her that surgery would be a success, and assured myself that there wasn’t enough time to answer her questions fairly. (Kalanithi, 2016, pp. 85-86)

In the description of this situation, in which Kalanithi overlooks the appeal of the other, he confesses at the very moment the appeal has passed, that he has in fact heard the appeal: “But why didn’t I make the time?” (Kalanithi, 2016, p. 86).

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Care for the other begins as shiver and restraint It is apparent here how the care for the other does not begin as the positive movement of a grandly noble élan, but as a shock-experience: the possibility and at the same time the prohibition to abandon the suffering and dying other to its fate. Care responsibility does not begin with a commandment that prescribes what I must do, but with a prohibition that presents what for sure is not allowed. In the first place, it is not that I must do something concrete; on the contrary, I should not do something, namely simply walk on by or neglect the other, leaving the other to its suffering. In this regard, the prohibition that proceeds from the face of the other arouses in me the fundamental ethical feeling of the scrupule. Literally, the Latin scrupulus means a pebble in the shoe whereby someone cannot remain standing but is moved or enticed to take a next step. The scruple, therefore, understood as an unrest that works annoyingly, or as an unease and discomfort: I am made apprehensive by the prospect of doing violence to, or neglecting or violating the other in their vulnerability, whereby the other is delivered unto me (Levinas, 1981, pp. 6-7). This does not mean that there is no command to help or to come to assistence, as we will explain further. We can then label this original ethical movement towards the suffering other as “the apparently negative movement of restraint” (Levinas, 1999b, p. 126). Confronted with the vulnerability of the face, I am appealed to hold myself back and withdraw, meaning to say to not do something, namely not to add suffering to suffering by treating the other indifferently. The ethics towards the other begins as the paradox of shrinking or “selfcontraction” in the shamelessness and expeditiousness of my attempt-atbeing that rushes forward without looking right or left. The ethical relationship towards the other begins as a hesitation and shiver. Or as dread (effroi) about oneself, as a movement of withdrawal and questioning of the self: “Gosh, what am I doing…? Am I perhaps being too self-certain? Am I denying the other perhaps through my way of reacting or acting?” (Levinas, 1981, pp. 84, 87, 192). Thus Kalanithi (2016) says during his assistantship: I feared I was on the way to becoming Tolstoy’s stereotype of a doctor, preoccupied with empty of formalism, focused on the rote treatment of disease—and utterly missing the larger human significance. (…)

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Amid the tragedies and failures, I feared I was losing sight of the singular importance of human relationships, not between patients and their families, but between doctor and patient. Technical competence was not enough. (p. 186)

The fundamental ethical choice consists in not covering up or brushing aside the crisis that the other brings about in us, in not undoing the unease that the face arouses in us through all sorts of techniques and strategies, but on the contrary enduring this crisis and that unease as a choice not to desert the other in its suffering. Responsibility as compassion and goodness This apparent negative movement of restraint and questioning of the attempt-at-being is but a starting point for it opens up room and perspective in the attempt-at-being for the positive movement of attention and acknowledgement, responsibility and care for the other. Time and again in all his writings, Levinas characterises this responsibility—that lives up to the do-not-kill the other and that proceeds from the face as an appeal and is thus radically heteronomous—as “goodness” (Levinas, 1979, pp. 304-305). It is a term that is dear to him and of which the highest realisation consists, according to him, in being near, in assisting and in “bearing” the other in its utter vulnerability, even though the other cannot do anything in return anymore. Levinas also calls it “ethical motherhood” in the sense that the one person “bears the other in oneself until the other is born”: “gestation of the other in the same: bearing par excellence” (Levinas, 1981, p. 75). With this “motherhood,” Levinas points as well to sensibility, literally “being sensible” throughout one’s own bodiliness (Levinas, 2000, p. 179): “the psyche is the maternal body” (Levinas, 1981, p. 67). Our sensibility contains both the emotion and the “shock and shuddering due to the epiphany of the other” (Levinas, 1981, p. 97): being physically touchable and vulnerable. We already bear the other in our body: in and through our “embodied selves” (body-subject) we are susceptible—sensitive—to the suffering of the other, suffering that in its turn also manifests itself in and through the body of the other. In and through my exposed and vulnerable—sensitive—body, I am

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already connected to the other, even before I can actively connect myself (Benaroyo, 2017, p. 35). Levinas describes this bodily sensibility as the “compassion of solidarity” (Levinas, 1981, p.  117): it is the passion for the passion of the other (suffering through the suffering of the other). Compassion lies anchored in our bodily ensoulment through the other (Levinas, 1994, pp.  134-135). Levinas finds compassion as the pre-eminent characteristic of the human person, even though from a utilitarian perspective it seems a sign of pure foolishness. Ultimately, suffering due to the suffering of the other is a beginning of a difficult beinghuman, not at all of rest and harmony. At the same time, this compassion is our highest human dignity. Compassion is a risk, but a risk that deserves to be taken if we want to be sensitive by and for the other (Levinas, 1990, pp. 42-45). The passion for the passion of the other, however, cannot remain passive; it must become effective in and through deeds of goodness. Compassionate goodness as an actively taken-up care for the affected and suffering other does not limit itself to a negative restraint that recoils from abandoning the other to its fate, but develops into a  longing to assist the other. The only way in which I can be near the other is with my capacities and achievements, in short with my attempt-at-being. I must not bracket away or destroy my egocentric attempt-at-being, but rather transform it and make it available at the other’s disposal. After all the foregoing, Kalanithi (2016) thus says: With my renewed focus, informed consent—the ritual by which a patient signs a piece of paper, authorizing surgery—became not a juridical exercise in naming all the risks as quickly as possible, like the voiceover in an ad for a new pharmaceutical, but an opportunity to forge a covenant with a suffering compatriot: Here we are together, and here are the ways through—I promise to guide you, as best as I can, to the other side. (p. 88)

With “as best as I can,” Kalanithi especially means striving for “technical excellence”—he is after all a neurosurgeon. That is what he says he has learned from the pain of compassion: The pain of failure had led me to understand that technical excellence was a moral requirement. Good intentions were not enough, not when so

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much depended on my skills, when the difference between tragedy and triumph was defined by one or two millimetres. (p. 105)

Kalanithi considers it his ethical task to be very professional. At the same time, he makes it clear that this tangible and expert medical assistance must be complemented with and framed by sufficient relational and ethically inspired assistance. This caring goodness full of compassion for the suffering other unfolds itself from the inside-out, namely as an inner urge—as an internal must or “not being able to do otherwise,” which is at the same time ordered of us and develops into an utterly positive dynamism of involvement in the other. We must do even more than we must do according to the rules of ethics of common sense: “a proximity never close enough” (Levinas, 1981, p. 138). We are aware that we must go farther than what duty asks of us. Kalanithi himself (2016) realises this: The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight. (p. 98)

To the extent that Kalanithi takes up his responsibility for the other, a longing grows within him—and the ethical appeal—to substantiate even more and extend that goodness. It far surpasses the goals of “legal or rule ethics.” Grounded in and moved by the appeal that proceeds from the suffering of the other, compassionate goodness deepens itself into a skill and an art that continually refines and qualifies itself even more, propelled as it were by an “insatiable compassion,” “not because it answers to an infinite hunger, but because it does not call for food” (Levinas, 1987b, p. 56). Meaning to say: into a fullness of dedication and commitment, that finds in itself not enough dedication and commitment. Kalanithi experiences that too: in principle, he can never again say: “Now it is enough, I do not care anymore about this.” Indeed, one can go so far in the commitment to the other so that one, coupled with extreme forms of self-sacrifice, ends up in self-destruction and moral paternalism of the other. The introduction of a certain “frugality” in the commitment to the other whereby that commitment remains enduring and

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feasible is thus absolutely important and ethical insofar as it is not to the other’s benefit that I fall flat on my face, so to speak. This, however, does not prevent that in responsible compassion, as Levinas sketches, a surpassing of the law is present in the sense that no single prescription could still or may still secure its achievements. Strictly speaking, the task of responsible and compassionate care for the other puts no single limit before itself. On the contrary, it opens up a perspective towards infinity that time and again makes itself infinite, literally “infinitizing,” even though that task thereby is and remains again a source of annoyance and rejection (Levinas, 2006b, pp. 29-30). Responsibility as a small goodness Through his own suffering and deterioration, Kalanithi becomes even more clearly aware of the infinitizing of responsibility for the other. Towards the end of his book, he writes: My own hubris as a surgeon stood naked to me now: as much as I focused on my responsibility, a fleeting power. Once an acute crisis has been resolved, the patient awakened, extubated, and then discharged, the patient and family go on living—and things are never quite the same. A physician’s words can ease the mind, just as the neurosurgeon’s scalpel can ease a disease of the brain. Yet their uncertainties and morbidities, whether emotional or physical, remain to be grappled with. (Kalanithi, 2016, p. 166)

At the same time, he experiences as a patient how his doctor—Doctor Emma—does not abandon him, even though at a given moment the tide can no longer be turned and they both know where this all is going to end. Even though she can “in-deed” not do much more for him, she still means much to him by being there, with him and his suffering, knowing that she can do nothing more. Seeing the suffering other lying there means being called upon not to leave him alone, even though I can do nothing and I can only answer with a lingering nearness: holding the hand of the other, without the other being able to or having to do something in return (Levinas, 1985, p.  119). With Levinas we can also call this the “true consolation”

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that stands in sharp contrast to the compensation or the reciprocity of the do ut des or the reward given “for all the trouble” (Levinas, 1978, pp. 49-50). In order to explain what he means, Levinas makes a connection between consolation and caress. The caress is an extraordinary phenomenon, in the sense that the one who caresses touches and not touches at the same time: in the act of caressing—an act of nearness—the caressing self withdraws each time from the caress. Caressing is a careful and care-filled, a delicate and tender touching of the other (Levinas, 1994, p. 134). The caress of a consoler which softly comes in our pain does not promise the end of suffering, does not announce any compensation, and in its very contact, is not concerned with what is to come with afterwards [as recompense]; it concerns the very instant of physical pain, which then is no longer condemned to itself, is transported ‘elsewhere’ by the moment of the caress and is freed from the vice-grip of ‘oneself,’ finds ‘fresh air,’ a dimension an a future. (Levinas, 1978, p. 91)

Authentic comfort does not escape from the present, from the current (physical, psycho-somatic, spiritual…) pain of the other, to present one or the other (illusory) recovery: “Take comfort, it will all be better tomorrow.” Comfort comes to stand in the present of the suffering of the other in order to touch her or him here and now carefully—literally with restraint—and be near, without empty promises. The comfort of the caress or the consolation as caress brings us, in conclusion, to what Levinas calls the small goodness. In the appearance of suffering against which “nothing is possible,” Levinas speaks of a small goodness that is “fragile and temporary,” a goodness “without witnesses,” taking place in silence, modest, cursory, without triumph. It is also gratuitous in the sense that it actually is not much trouble, and precisely for that reason it is eternal and you can persevere in that goodness. It is the common people, “sensitive spirits,” who defend it or exercise it time and again, without adamantly defending it. Inconspicuously, it sees to it that it picks itself up again after a fall, even though it is completely defenceless. The paltry goodness struggles to sit upright, like a downtrodden blade of grass

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stubbornly but noiselessly stands up again. It may be crazy—a “foolish” goodness. Foolish because it is capable of and effectuates little, let alone is “effective” and “utilitarian.” At the same time, it is that which is most humane in the human person. It determines, no, it inspires people in spite of their powerlessness. It is beautiful in its powerlessness, like the morning dew. It never conquers, but is also never conquered. The small goodness allows us not to abandon the other in its suffering, even though we are not able to alleviate, let alone eliminate, this suffering (Levinas, 1999, pp. 107-109).

Conclusion: Care-filled and careful Care ethics genuinely emphasizes the relational dimension of subjectivity and caring (Gilligan, 1982; Noddings, 1984; Tronto, 1993). But the normative dimension of this phenomenology is—or was—weak and insufficiently developed (Nortvedt, 2007). Therefore our focus on the Levinasian appeal to responsibility-by-and-for-the-Other as normative core of care ethics (Diedrich et al., 2006). Out of a multidimensional, holistic approach to the suffering of the other, we discovered the appeal to be near and to assist the other in both a carefilled as well as careful manner. A “care-filled” care puts the emphasis on the fundamental attitude of responsibility. Even though this responsibility begins before our freedom, it takes place in the concrete practice of care as the virtue of responsibility whereby attuning oneself to the suffering other is a never-ending process of growth, integrating the care for caregivers and the responsibility for their own responsibility. Such a care-filled attitude and relationship of responsibility therefore requires, in practice, carefulness, based on the development of knowledge, but especially of skills that time and again have to be tested on the reality of the suffering other and the appeal to care-filled care that attunes itself “in-deed” to the suffering other. Only by doing so does care grounded on an ethics of care acquire shape as a “nearness that is never near enough,” thus citing our source and teacher, Levinas (1981, pp. 83-87), a nearness that is at the same time marked by hesitation and restraint, afraid as it is of crushing, objectifying and possessing the other.

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Literature Benaroyo, L. (2017). Soin et vulnérabilité: Les ressources éthiques de la pensée d’Emmanuel Levinas. In Jousset, D., Boles, J.-M., & Jouquan, J. (Eds.), Penser l’Humain vulnerable. De la philosophie au soin (pp. 27-37). Rennes: Presses Universitaires. Collins, S. (2015). The Core of Care Ethics. London: Pallgrave-Macmillan. Diedrich, W.W., Burggraeve, R., & Gastmans, C. (2006). Towards a Levinasian Care Ethic. A Dialogue between the Thoughts of Joan Tronto and Emmanuel Levinas. Ethical Perspectives 13 (1), 33-61. Gilligan, C. (1982). In a Different Voice. Psychological Theory and Women’s Development. Cambridge/London: Harvard University Press. Kalanithi, P. (2016). When Breath Becomes Air. New York: Random House. Levinas, E. (1978). Existence and Existents. The Hague: Martinus Nijhoff. Levinas, E. (1979). Totality and Infinity. An Essay on Exteriority. The Hague/Boston/ London: Martinus Nijhoff Publishers. Levinas, E. (1981). Otherwise than Being or Beyond Essence. The Hague/Boston/London: Martinus Nijhoff Publishers. Levinas, E. (1985). Ethics and Infinity. Conversations with Philippe Nemo. Pittsburgh, PA: Duquesne University Press. Levinas, E. (1987). Time and the Other (and additional essays). Pittsburgh, PA: Duquesne University Press. Levinas, E. (1987). Collected Philosophical Papers. Dordrecht/Boston/Lancaster: Martinus Nijhoff Publishers. Levinas, E. (1990). L’éthique est transcendance (Entretiens avec le philosophe Emmanuel Levinas, avril 1986, par Emmanuel Hirsch). In Hirsch, E., Médicine et éthique. Le devoir d’humanité (pp. 38-46). Paris: Cerf. Levinas, E. (1994). Une éthique de la souffrance (Entretien avec Emmanuel Levinas par Jean-Marc Norès). In von Kaenel, J.-M. & Ajchenbaum-Boffety, B. (Eds.), Souffrances. Corps et âme, épreuves partagées (pp. 127-137). Paris: Éditions Autrement. Levinas, E. (1998). Of God Who Comes to Mind. Stanford, CA: Stanford University Press. Levinas, E. (1999). Alterity and Transcendence. New York: Columbia University Press. Levinas, E. (1999). New Talmudic Readings. Pittsburgh, PA: Duquesne University Press. Levinas, E. (2000). God, Death, and Time. Stanford, CA: Stanford University Press. Levinas, E. (2001). The Vocation of the Other (Interview by Emmanuel Hirsch). In Robbins, J. (Ed.), Is It Righteous to Be? Interviews with Emmanuel Levinas (pp. 105113). Stanford, CA: Stanford University Press. Levinas, E. (2003). On Escape. Stanford, CA: Stanford University Press. Levinas, E. (2006). Entre Nous. Thinking-of-the-Other. London/New York: Continuum. Levinas, E. (2006). Humanism of the Other. Urbana & Chicago: University of Illinois Press.

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Marcel, G. (1951). The Mystery of Being, Volume I: Reflection and Mystery. London: The Harvill Press. Noddings, N. (1984). Caring: A Feminine Approach to Ethics and Moral Education. Berkeley: University of California Press. Nortvedt, P. (2007). Care, Sensitivity and “The Moral Point of View”. In Gastmans, C., Dierckx, K., Nys, H., & Schotsmans, P. (Eds.), New Pathways for European Bioethics (pp. 81-91). Antwerpen: Intersentia. Ricoeur, P. (2001). Le Juste 2. Paris: Editions Esprit. Thévenot, X. (1997). Avance en eau profonde. Carnet spirituel. Paris: Desclée de Brouwer/Cerf. Tronto, J. (1993). Moral Boundaries: A Political Argument for an Ethic of Care. London/New York: Routledge. van Heijst, A. (2011). Professional Loving Care. An Ethical View of the Healthcare Sector. Leuven: Peeters.

Confronting Neoliberal Precarity: The Hyperdialectic of Care Maurice Hamington1

On December 8, 2011, Chicago resident Carlos Centeno Sr. died of injuries suffered three weeks earlier from a workplace hot acid spill that burned much of his body. Following the spill, Centeno was not cared for expediently or properly and suffered greatly (Morris and Mitchell). A Mexican native and father of three, Centeno came to the United States in 1994, followed a few years later by his partner, Vella Carbot. He held short-term jobs bartending, driving forklifts, and delivering newspapers. After being laid off in 2010, Centeno joined an agency that specializes in temporary work assignments. He was subsequently assigned to a home products manufacturer of household goods including shampoos, styling gels, deodorant sticks, dishwashing liquids and household cleaners. His starting pay was $8.25US per hour. Prior to his death, Centeno and other workers experienced a number of personal injuries that appear to be the result of safety protocol failures. “I wanted him to quit,” indicates Carbot, “but, at the same time, we knew he hadn’t found another job yet, and expenses continued, unfortunately, and he had to work” (Morris and Mitchell). Like many others working low-paying and dangerous jobs, Centeno was a victim of circumstances created by neoliberal precarity, and doubly so as both an immigrant and a contingent laborer.2 1 Many thanks to Michael Flower, Frans Vosman, and Per Nortvedt whose careful reading and critical analysis significantly contributed to this chapter. 2 The negligence in Centeno’s case may have been egregious but not unusual given the increasing utilization of contingent labor. Depending upon the definition

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This chapter challenges neoliberalism and questions society’s relationship to Carlos Centeno. Why should I care about Centeno? He is not a member of my family or among my friends. He is just another human being among the billions of others that live on this earth. One of the goals for most care theorists is to expand the circle of care beyond familiar friends and family. This goal is often opposed by neoliberal ideology. Neoliberalism represents a powerful narrative regarding human individualism. It describes a set of political practices as well as an atomized philosophy and disposition that has been widely internalized in the United Stated and the modern developed world. One outcome of neoliberal thinking is to circumscribe the extent and depth of contemporary moral relationships with others. When American television host Jimmy Kimmel offered a tearful description of his newborn child’s need for heart surgery and expressed his concern that many people in the United States would not be able to afford such medical care, former Illinois congressman Joe Walsh, tweeted, “I am sorry about your baby but your story does not obligate me to pay for other people’s health insurance” (Zorn, 2017). We may find such a statement reprehensible but this sentiment reflects neoliberal ideas that separate us from one another: your problems are not my problems. Neoliberalism endeavors to make care a private responsibility. Accordingly, we are limited to adjudicating violations to Centeno’s rights rather than reformulating social systems that create disposable workers. In a perhaps unexpected of contingent labor, the percentage of the U.S. labor force in these positions varies from 5 to 40%. However, the number of contingent laborers is on the rise (Murray and Gillibrand, 2015). It can be argued that contingent labor can provide workers with flexibility and may be desirable for some, however, workers generally desire security and consistency not afforded in this trajectory. Similarly, migrant workers face precarious working conditions. For example, in a 2016 survey of non-government organizations who work with temporary and seasonal foreign workers, sponsored by the Canadian Council for Refugees, respondents reported concerns about violation of workers’ rights (43%), lack of job security (39%), financial problems (31%), racism (25%), inadequate housing (24%), unsafe working conditions (23%), and debt from recruitment fees (13%) (2016, p. 9). Contingent and migrant labor are only two aspects of contemporary social precariousness driven by the implementation of neoliberal policies and practices of free markets.

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manner, this chapter challenges neoliberalism by attacking its underlying assumptions through an integration of Maurice Merleau-Ponty’s phenomenological ontology3 with care ethics. Rather than suggest policy and practice changes as many care theorists have persuasively offered (Engster, 2007; Tronto, 1994, 2013), I contend that MerleauPonty offers care theory an ontological path for decolonizing the contemporary mind from neoliberal thinking.

Overview of the Argument In The Visible and the Invisible (1968), Maurice Merleau-Ponty posits what has become known as the “reversibility thesis” to describe the radical ontological connection humans have to one another and the phenomenal world. In perhaps a far too cryptic explanation, the reversibility thesis can be described as the idea that because humans can be both subject (touching) and object (touched) in the phenomenal world, we share in existence (being). A “hyper-dialectic” is Merleau-Ponty’s term for a radical method of interrogating the world that eschews certainty or truth in favor of better and better understanding. This chapter argues that in his reversibility thesis and hyperdialectical method,4 3 Ontology, or the branch of metaphysics which addresses the study of being, is a source of robust philosophical discussion with significant distinctions as witnessed in the other contributions to this volume. This chapter does not offer a comprehensive discussion of ontology but rather focuses on the operative ontological assumptions suggested by neoliberal thinking versus care ethical thinking. Specifically, the role of relationality in ontological thinking is addressed in subsequent sections. Carefully defining terms is crucial to ontological conversations. The use of relational ontology here is particularly pragmatic in service of addressing contemporary social morality. As such, the use of the term “ontology” in this chapter should not be taken as necessarily in opposition to those who question the role of ontology at all in normative considerations such as in Dewey or Putnam (2004). 4 Merleau-Ponty’s notions of hyperdialectic and reversibility thesis do not lend themselves to easy explanations and each are more fully discussed later in this chapter. He offers the idea of hyperdialectic as an improvement to Hegel’s dialectical method as a complex means for interrogating a dilemma including questioning the interrogation itself. The reversibility thesis is a means for explaining the phenomena of human beings as both subjects and objects in a manner that connects us all to one another.

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Merleau-Ponty provides care ethicists with further tools to construct a critical theory of care to counter neoliberalism and its resultant approach to governance which has caused precarity to permeate contemporary society. Specifically, I claim that the reversibility thesis points to an extremely deep ontological connection that we have to one another and the hyperdialectical method provides a practice for leveraging that intersubjective connection to its full potential in caring for one another. In applying Merleau-Ponty’s intersubjective mind/body ontological approach to caring, this chapter begins by addressing the implications of the reversibility thesis including both primal empathy and hyperdialectic method for living which is particularly apt for interrogating a relational and caring existence. For instance, Merleau-Ponty’s hyperdialectic implicates a sense of wonder for diverse intersectional experiences and an emergent normativity rather than a priori ethical structures typically used in moral theory. In other words, one does not come to situations presupposing answers or that there even is an answer to the question of what the right thing to do is. Given the ontological commitment to one another offered by Merleau-Ponty, the chapter then turns to the philosophical assumptions of neoliberalism and the widespread precarity they have fostered. In particular, the steadfast devotion to individual liberty and freedom is critiqued for overlooking the fundamental relational being of humanity. Employing the primary sense of empathy that emerges from MerleauPonty’s work, the conclusion describes embodied care as a critical theory that both resists a possession-based approach to freedom in favor of a relation-based approach and reinforces the psycho-social dimensions of care that are equally significant as political practices and policies. Care is therefore embodied and ontological a well as personal and political.

The Reversibility Thesis Although there is significant literature that addresses the intersection of Merleau-Ponty’s philosophy and feminist philosophy (Olkowski & Weiss, 2004), there are relatively few interrogations of the relationship between Merleau-Ponty’s phenomenology of the body and care

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ethics (Hamington, 2004; Brubaker, 2006). This absence is perhaps somewhat surprising given their shared commitments to relational human ontology and particularism of experience. Because feminism gave rise to care ethics, and feminism has a longstanding concern for issues of embodiment, it appears that Merleau-Ponty’s work is ripe for exploration. In Embodied Care, I indicated that a robust ethic of care was best described as an approach to morality employing habits of the mind and body (Hamington, 2004). To make the argument, I utilized Merleau-Ponty’s discussion of perception, figure-background phenomenon, and his concept of the flesh to construct a corporeal approach to the epistemology of care. In this chapter, my focus shifts to leveraging Merleau-Ponty’s relational ontology, particularly as it is developed in The Visible and the Invisible, to establish care as a way of human being. Specifically, Merleau-Ponty’s reversibility thesis claims we are radically interconnected. If care is indeed an ontic reality then the individualistic assumptions that underlie contemporary neoliberalism run counter to what might be described as our nature. The conclusion, then, is not simply that the arguments for liberalism are wrong, but that the presuppositions of liberalism (and thus neoliberalism)5 distort reality and can be resisted through a hyperdialectic of care. Tantalizing, unfinished, and published posthumously, The Visible and the Invisible describes a perceptual approach to reality that intertwines us all—as subject and object, perceiver and perceived. Limited by language and the pervasiveness of dichotomous structures of thinking, Merleau-Ponty (1968) struggles to explain deep interconnectedness without postulating a singularity: In a sense the whole of philosophy, as Husserl says, consists in restoring a power to signify, a birth of meaning, or a wild meaning, an expression of experience by experience, which in particular clarifies the special The terms “liberalism” and “neoliberalism” have distinct usages and complex histories that are not delineated fully in this chapter. “Neoliberalism” is used here to describe a contemporary social and political movement that emphasizes competitiveness and advocates marketizing social institutions resulting in the creation of inequality. For a comprehensive literature review of the history of neoliberalism see Davies, 2014. 5

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domain of language. And in a sense, as Valery said language is everything, since it is the voice of no one, since it is the very voice of the things the waves, and the forests. And what we have to understand is that there is no dialectical reversal from one of these views to the other; we do not have to reassemble them into a synthesis: they are two aspects of the reversibility which is the ultimate truth. (p. 155)

Merleau-Ponty is offering a non-dualistic ontology. It is through the “necessity” of ontology that Merleau-Ponty hopes to transcend contemporary crises in philosophy and politics (1968, p. 165). He points to a radical departure in philosophical thinking by claiming, “it has become necessary to start anew” (1968, p. xxiii). Merleau-Ponty begins with a tactile approach by describing the difference and sameness of the experience of being touched and touching (1968, pp. 133-134, 143). This reversibility presents a challenge to our modernist, categorical framework of understanding. Touching and being touched are discrete perceptual experiences and yet these experiences are understood in relation to one another through bodily perception. Anya Daly (2016) describes that for Merleau-Ponty, “The touching/touched are unified within the one system, which is the body, and so are symmetrical—there is overlapping and encroachment” (p. 66). The difference between touching and touch is crucial because perception is not the same as being the object of perception. So, when one touches oneself, there is difference within the symmetry of experience (Dillon, 1997, p.  159). There is unification in the body but the experience is non-coincidental—it is not felt or thought of as simultaneous and must be disambiguated in our understanding of the phenomenon. This reversibility or “identity-in-difference” (Daly, 2016, p.  66) is the structure of our ontological connection to the world. We can grasp interiority and exteriority because we inhabit both. Accordingly, no one is entirely alien to me because I can apprehend an aspect of them in myself, yet they are not me (Dillon, 1983, p. 377). Through touch, Merleau-Ponty (1962) recognizes the liminality of the self/ other distinction: “it is precisely my body that perceives the body of another, and discovers in that other body a miraculous prolongation

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of my own intentions, a familiar way of dealing with the world” (p. 354). Merleau-Ponty makes a similar reversibility claim about the visible, or phenomenal world, and the invisible: “The visible can fill me and occupy me only because I who see it do not see it from the depths of nothingness, but from the midst of itself; I the seer am also visible” (1962, p. 113). For Merleau-Ponty, there is not a formulaic disjuncture of X sees object Y.  Indeed, X sees and makes sense of Y because X and Y are phenomenally related, i.e. because Y is also a phenomenal object that can be seen. Dillon (1997) explains, The ontological significance of this identity-within-difference needs to be stressed. Coincidence in self-perception is one of the grounds of the traditional isolation of the epistemological subject: it provides the basis for the theses of corrigibility of the first person experience and transparency in the sphere of immanence which lead to the radical bifurcation of interiority and exteriority or consciousness and thing/ Other/world. Similarly, absolute disjunction of perceiving and being perceived also produces a discontinuity between being-a-subject and being-an-object. The only way to evade the trap of the polarizations of dualism is to take up the standpoint, adopted by Merleau-Ponty, of a fundamentally ambiguous identity-encompassing-difference. It is this ambiguity that Merleau-Ponty articulates in the thesis of reversibility. (p. 159)

There is interconnection and intertwining between phenomenal objects but not identity or sameness. Paradoxically, coincidental to interconnection, there is rupture, a chiasm, between touching and being touched as well as between being seen and seeing, yet each side of the perceptual non-coincidental experience is informed by the other and synthesthetically unified through the body (Dillon, 1997, p. 160). For Merleau-Ponty, phenomenology captures both otherness and continuity. Merleau-Ponty offers “flesh” as a radical concept for unified ontology marked by reversibility. The seeds for the ontological concept of flesh were planted earlier in Merleau-Ponty’s work. For example, in “Eye and Mind” (1964), Merleau-Ponty moves from an expansive

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understanding of embodiment to positing an interconnected existence: Visible and mobile, my body is a thing among things; it is caught in the fabric of the world and its cohesion is that of a thing. But because it moves itself and sees, it holds things in a circle around itself. Things are an annex or prolongation of itself; they are incrusted into its flesh; they are part of its full definition; the world is made of the same stuff as the body. (p. 163)

Merleau-Ponty (1968) views “flesh” as a wholly novel idea: “There is no name in traditional philosophy to designate it” (p. 139). He then labors to describe what flesh is: “The flesh is not matter, is not mind, is not substance … [but rather] a sort of incarnate principle that brings a style of being wherever there is a fragment of being. The flesh is in this sense an ‘element’ of Being” (1968, p. 139). Commentators have also negotiated within the limits of language to explain Merleau-Ponty’s notion of flesh. For Diana Coole (2007), Merleau-Ponty’s ontology of the flesh constitutes an “interworld where meaning and materiality are simply inseparable” (p. 100). Daly (2016) writes that according to Merleau-Ponty, the interworld is not something I resolve to live in; it pre-exists any decisions, underwrites any ethical pacts and ensures reciprocity and co-existence. The interworld is the primordial ‘we’, and in protecting the ‘we’, the welfare of the other is already my own and it is non-negotiable. (p. 287)

Similarly, Galen A. Johnson (1999) describes flesh as, “the ontological hinge on which the outside passes over to the inside and inside passes over to outside” (p. 31). Challenging the modernist categorical thinking that underlies language (Hass, 2008, p. 131), Merleau-Ponty uses flesh to discuss an ontology that recognizes ambiguity and is liminal, non-dualistic, embodied, and connected to others in the world. Flesh, the interworld6 between the intercorporeal and the 6 The term “interworld” is an effort at describing how people are not completely alienated from what one another are feeling in the interior: “We must reject the prejudice which makes ‘inner realities,’ out of love, hate or anger, leaving them

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intersubjective (Coole, 2007, p.  242), defies explicit attempts to understand it as merely the sum of its parts. Because of its primal interconnectedness, the interworld is the flesh of the political and thus posits the political as originary rather than a socially constructed addition. In this context, political means the negotiation between individuals which for Merleau-Ponty takes place on the interior at the level of being and not just in the public square. Merleau-Ponty is describing relationality at an ontological depth that is beyond how care theorists have historically characterized the relationality of care.

Deepening the Notion of a Relational Ontology Many theorists, including myself, refer to the underlying relational ontology that supports care ethics (Hamington, 2017, p. 267; Nortvedt et al., 2011, pp. 194-196; Pettersen, 2011, pp. 52-53; Puig de la Bellacasa, 2017, p. 100; Robinson, 1999, p. 110; Sevenhuijsen, 1998, p. 10). Their use of “relational ontology” refers more often to psychosocial and existential sense of identity and self rather than to a strictly philosophical understanding of ontology as the study of being. For example, Robinson (1999) describes, a critical ethics of care begins from a relational ontology; it highlights the extent to which people ‘live and perceive the world within social relationships’ while, at the same time, recognizing that people use relationships to construct and express both power and knowledge. (p. 110)

The arguments for relational ontology among care ethicists are usually developmental in nature suggesting that humans are social animals that need one another to care for one another given our fundamental vulnerabilities or we will not survive. Such claims are not challenged here. However, if we take the reversibility thesis seriously, particularly through Daly’s compelling analysis, Merleau-Ponty is claiming more accessible to one single witness: the person who feels them. Anger, shame, hate, and love are not psychic facts hidden at the bottom of another’s consciousness: they are types of behavior or styles of conduct which are visible from the outside. They exist on this face or in those gestures, not hidden behind them” (Merleau-Ponty, 1970, p. 253).

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than the idea that a relational ontology leads to a relational ethic. He is arguing that we are radically connected to the extent that empathy and relational ethics is who we are. By claiming the ontological connection through the reversibility of the flesh, Merleau-Ponty is suggesting that the relational ethic is already extant in the self. Daly (2016) captures the depth of the intersubjective ontology proposed by the reversibility thesis for which the reader may recognize similarities to themes found in the work of Husserl and Levinas: The reversibility thesis is the thesis that self, other and world are inherently relational, not in the obvious and trivial sense that they stand in relation to each other, can affect each other, that there are actual and potential causal connections between them. This without question is so and these relations occur between entities that are external to each other. Merleau-Ponty’s Reversibility Thesis, however, proposes that self, other and world are internally related, that there is interdependence at the level of ontology. What does it mean to be internally related? The Other, whether other subjectivities or the otherness of the world and things, is essential for self-awareness and vice versa. No self can be apprehended without an-other. Ipseity and alterity are mutually dependent and this interdependence is both pervasive and intrinsic. (p. 65)

As Daly indicates, Merleau-Ponty is challenging some of the fundamental questions of philosophy in addressing the problem of other minds as well as other bodies in creating a non-dualistic ontology. Similarly, David Morris (2010) describes the seer and the seen as the ontological reverse of one another: different shapes or inflections of one and the same being. “Reversibility” designates this phenomenal and ontological complicity of the seer and the seen and the perceiver and perceived in general, and designates this complicity as a function of being (not merely the perceiver): Being that is reversibly perceiver and perceived. (p. 144)

Rather than discrete action, experience is only fully realized in the totality of perception and being perceived. For Merleau-Ponty (1968), we understand one another because, we are “like organs of one single intercorporeality” (p. 142). What of deep divisions among humans and the conflict and violence that occurs? The identity-within-difference

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offered by Merleau-Ponty’s ontology is not Pollyannaish in regard to disagreement and divergence. What Merleau-Ponty is pointing out is the fundamental ability of human beings to find themselves in others. There may be disagreement but there is always hope for collaboration given this relational ontology. Merleau-Ponty did not have the benefit of engaging the contemporary field of care ethics. Although many care theorists have implicitly or explicitly framed care ethics as a recasting of traditional philosophical approaches to normative morality, Merleau-Ponty’s phenomenology of the body gestures toward Joan Tronto’s description of humanity’s essential caring being (2017). Despite rampant neoliberal narratives of individualism that reinforce our alienation from one another, we cannot avoid our fundamental connection and the primacy of empathy as an important aspect of care.

Primary Empathy One of the implications of Merleau-Ponty’s reversibility thesis is an ontological basis for understanding empathy in human intersubjectivity. If through the flesh, the phenomenal world is within us, then the starting place for bridging alterity is also within us. Reversibility makes the intersubjective world possible in such a way that we do not confront wholly “other” persons but rather engage people with whom we have existing internal connections that can be drawn upon. In other words, fellow-feelings are built into our mind-bodies. Daly (2016) refers to the ontological character of fellow-feelings as “primary empathy”: I propose that empathy as fellow-feeling is an essential mode of intentionality, integral to the primary level of subjectivity/intersubjectivity, which is crucial to our survival as individuals and as a species … empathy is not derived on the basis of intersubjectivity, nor does it merely disclose intersubjectivity; rather it is constitutive of intersubjectivity at the primary level. Empathy is a direct, irreducible intentionality separable in thought from the other primary intentional modes of perception, memory and imagination, but co-arising with these (p. 225).

Daly utilizes the reversibility thesis to further nest Merleau-Pontian ethics within ontology (2016, p. 231). In other words, to be human

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is to empathize. If care ethics is indeed a radical reconsideration of what it is to be human rather than just a normative theory of ethics, the questions shift from positive considerations of what it takes to motivate care to questions regarding why we do not care more given our primary empathy. Empathetic is who we are as human. As Douglas Low (1994) describes, in Merleau-Ponty’s ethics, “there is here an empathy and identification with the other, an overlapping of ego boundaries to include others. Morality then has its source the recognition of human beings as human beings” (p.  181). No one would deny that humans have blood running through their veins or are capable of thinking. Similarly, what is suggested here is that empathy is an ontological aspect of humanity and no one should deny the capability of humans to empathize.7 Many care theorists address the role of empathy (Hamington, 2015a, 2017; Noddings, 2010a, 2010b, 2010c; Verducci, 2000), but perhaps none has placed so much emphasis on the centrality of empathy for care ethics as Michael Slote (2007, 2010). Slote (2007) contends that care should be referred to as “empathetic care” (p. 14). He endeavors to frame care as a normative theory of ethics for which empathy adjudicates the rightness and wrongness of acts. Ultimately, Slote argues that empathy is the defining and central element of a normative theory of care. For Slote, actions can be deemed morally right or wrong and “contrary to moral obligation” depending upon whether, “they reflect or exhibit or express an absence (or lack) of fully developed empathic concern for (or caring about) others on the part of the agent” (2007, p. 31). Slote criticizes liberal thinking for overlooking emotion and supporting a deontological approach that is inadequate to a variety of moral conflicts which are better addressed by care (2007, pp. 80-81). Despite his criticisms of liberalism, Slote As I indicated in Embodied Care, humans are “built to care” (Hamington, 2004, p.  31) However, being built for care and actualizing care are two different things. This is one reason why I believe that a performative framework (Hamington, 2015a) is a particularly apt method for describing and understanding the caring person. A  performance is an action in the world that displays both agency of choice and influence over self-identity in the iteration of habits. 7

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is still postulating care ethics as an alternative normative theory. In this manner, he implicitly uses the language of liberalism in terms of individual agents who have moral obligations and act in ways that can be clearly adjudicated as right or wrong. Slote’s reliance on virtue theory reinforces the atomistic ontology of liberalism: “I have argued that the individual trait or virtue of (empathetic) caring is ethically more fundamental than caring relationships” (2007, p.  86). Slote’s work has added tremendously to the care scholarship on empathy, but his formulation is perhaps not as radical as he suggests or as fundamental to being as care ethics requires. What Merleau-Ponty has done is to intertwine ethics into ontology rather than overlay psychological or sociological relational forces. The above critique of Slote is not to deny the existence of those psychological or sociological forces but Merleau-Ponty offers care theorists something much more radical and powerful in the notion of primary empathy. Usually, the driving motivation for care ethical thinking has been interrogating how to expand the circle of care to include unfamiliar others (Slote, 2007, p. 11). However, the reversibility thesis suggests we have a primordial connection to others and a predilection for empathy which indicates that rather than interrogating how to expand the circle, perhaps the question is why don’t we exhibit greater care for one another given our primary empathy? What prevents the actualization of our intersubjective being? Of course, empathy is an essential starting place for care but in the spirit of Merleau-Ponty’s non-dualistic, non-coincidental ontology, empathy is not a binary state as represented by existence or absence. Feelings and cognitive understandings supporting empathy can be refined or strengthened through inquiry, broadly defined. This refinement process is essential to quality care. Without inquiry, without the questioning to better understand the other and their context, care can be disastrously insufficient or misplaced. Empathy is also not a sufficient condition of care because any number of factors may prevent empathy from being actualized into action. Care is an action responsive to the needs and context of the person cared for, utilizing the best understanding possible (Sevenhuijsen, 2000) and this can

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include and be supported by what is fundamentally shared at the level of being between the care-giver and the one cared-for. MerleauPonty’s notion of the hyperdialectic offers care theorists a method for empathy attunement consistent with the relational ontology of the flesh.

Hyperdialectics of Care and Emergent Normativity To summarize the journey of this chapter thus far, Merleau-Ponty’s reversibility thesis suggests a deep relational ontology that finds ethics originary including a primary empathy. Merleau-Ponty’s phenomenological ontology and its relational character not only vindicate care theory, it suggests that the notion of care can be used to describe a phenomenon that exceeds a normative theory of ethics. This section addresses Merleau-Ponty’s notion of a hyperdialectic to discuss agential methods of caring being. In other words, the ontological primary empathy does not negate a role for human agency. Merleau-Ponty offers a method of being described as a “hyperdialectic” that differs from extant dialectical approaches. Traditionally, a dialectic refers to a method of rational argument and truth seeking that involves some sort of contradictory process between opposing sides. The hyperdialectic, however, is a complex engaging of many relationships through language within the ambiguous complexity of human experience. Merleau-Ponty (1968) contrasts dialectical approaches: The bad dialectic begins almost with the dialectic, and there is no good dialectic but that which criticizes itself and surpasses itself as a separate statement; the only good dialectic is the hyperdialectic. …What we call hyperdialectic is a thought that on the contrary is capable of reaching truth because it envisages without restriction the plurality of the relationships and what has been called ambiguity. (p. 94)

Michael Berman describes Merleau-Ponty’s hyperdialectic as selfreflexive and indicative of an interrogative mode of existence that is always questing and questioning. This interrogation is not only cognitive but sensual as well— “our tactile senses always explore the world” (Berman, 2003, p. 405). Merleau-Ponty (1968) is once again traversing modernist categories by intertwining epistemology into ontology

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(and ultimately in service of ethics) by identifying “question-knowing” (p.  137) as a liminal quality of being in the interrogative mode of existence. Rajiv Kaushik describes the hyperdialectic as adding layers of analysis to the epistemic process as the subject reflects on the act of reflecting as well as the object of reflection, accumulating perspectives to consider in knowledge creation. Accordingly, the hyperdialectic “is a concrete site from where both the act of reflection and the thing upon which it reflects, subject and being, take their separate shape” (Kaushik, 2013, p.  6). The hyperdialectic approach implies humility in that categorical absolute truth is impossible and problematizes the distance between knower and the known. MerleauPonty’s desire to confront experience and all its ambiguities is evident in this approach. Taminiaux (1980) characterizes the hyperdialectic method as “gliding back and forth between ambiguity and synthesis” (p. 73). More than scientific inquiry, the hyperdialectic confronts the world with a sense of wonder in pursuit of an understanding that Merleau-Ponty (1962) had previously suggested was the purpose of phenomenology (pp. xii-ix, xvii-xix). The hyperdialectic reflects the situatedness of the mind-body as we question and make meaning from our visceral experience. The kind of engagement necessary for caring suggests a need for the complex interconnections found in Merleau-Ponty’s hyperdialectic method. Caring is a quest for knowledge (Dalmiya, 2002, p. 49), broadly defined, not simply through intellectual inquiry but through all that is brought to each human encounter in the flesh. The habits of caring include the epistemic skills of listening, questioning, learning, and growing—broadly and complexly construed to match the vicissitudes and richness of human existence. For example, the resources for effective responsive care must include understanding the intersectional identity. Intersectional identity refers to the multiplicity of socially meaningful characteristics including, but not limited to race, gender, class, sexual orientation, ability, etc. that influence how individuals are treated both in terms of oppression and privilege (Crenshaw, 1991, pp.  1244-1245). Acknowledging intersectionality contributes to the contextual learning necessary to effectively provide

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responsive care in any given situation (Hamington, 2015b). A hyperdialectic method is compatible with such an approach. Caring is embedded in learning not for the sake of accumulating disjointed facts, but emerges from the reversibility between self and other in the flesh: the fundamental connection we have with others in our perceptual experience. Accordingly, caring knowledge is just as much about the self as it is about others. Care can be described as a form of inquiry (Hamington, 2017) and the “hyperdialectic of care” captures the complexity and ambiguity of caring inquiry, removing it from the modernist understanding of epistemology as a quest for certain and definitive knowledge. Hyperdialectic is suggestive of a verb rather than a noun—an open-ended journey rather than a definitive location. Sarah LaChance Adams (2011) describes hyperdialectic as addressing ambivalence, “the truth in the relation between terms—neither being nor nothingness, but becoming” (pp. 177-178). The notion of hyperdialectic as a type of becoming is apt because of the intertwining of ontology, epistemology, and ethics. The engagement with others is not an isolated transaction between separate autonomous agents but something much more sticky and complex. Such engagement is a non-coincidental reconnection with self in the other that manifests agency but in a manner that is the realization of potential within oneself and linked to others in the contiguity of the flesh. MerleauPonty has provided a means for better understanding ontological and epistemic aspects of caring. Merleau-Ponty is not afraid to address the ambiguity of existence by challenging dichotomies of mind/body, object/subject, immanence/ transcendence, self/other, and action/reflection. One strategy that Merleau-Ponty employs is to emphasize emergence over static category. As Scott Marratto (2012) describes, Merleau-Ponty’s philosophy pointedly aims to avoid any kind of reification of the subject, either as a mind or as a body and instead seeks to understand subjectivity as a dynamic an open-ended process of emergence. Subjectivity emerges with the emergence of meaning in the world on the basis of the self-articulating character of living movement. (p. 2)

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Accordingly, Merleau-Ponty’s reversibility thesis and hyperdialectic supports the notion that normativity is emergent from relational experience. In Western philosophy, normative ethics has described efforts to provide a general theory that describes how people ought to live.  Deontological, teleological, and virtue theories are dominant approaches to moral normativity. Many scholars view care ethics as an alternative to mainstream theories. However, taking Merleau-Ponty’s ontology seriously suggests a different framing for care ethics. Through the good dialectic, the hyperdialectic, engagement with the other is revelatory: I learn about the other and myself in context. Part of the epiphany is understanding the caring response called for in the moment. In other words, I do not know the best way to care for someone until I understand them and their situation. My experiences and habits of caring may indicate possible actions, but I will not know what to do until the potential caring action emerges from what I learn of the other’s needs. Invoking a rule or the calculation of consequences is not sufficiently responsive because it is an abstract imposition into the phenomenon. Coole (2007) argues that the hyperdialectic “is not a rationalist formula imposed on Being but a practising where existence folds over itself” (p. 110). Applying the hyperdialectic, a care approach is quite different from standard notions of ethical normativity that offer a priori rules, formulas, or structures to determining moral action. Emergent normativity is a moral demand that arises from within the individual and reconnects them with their primary empathy and continuity in the flesh. I must be willing to listen, learn, be creative, and act in order to effectively care. For Hegel, dialectic involves the reconciliation of ostensible paradoxes to arrive at absolute truth. Merleau-Ponty’s (1954/2007) notion of hyperdialectic engages more complexity and ambiguity: What then is obsolete is not the dialectic but the pretension of terminating it in an end of history, in a permanent revolution, or in a regime which, being the contestation of itself would no longer need to be contested from the outside and, in fact would no longer have anything outside it. (p. 295)

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Applying care to hyperdialectic method signifies that to realize our best selves—a flourishing of our nature or ontology—our primary empathy must be attuned for efficacious action. A hyperdialectic of care, then, describes an engaged and immersive method for living that leverages our relational ontology to seek better understanding of others and ourselves. This method of inquiry circles back to recognize that interrogation of unfamiliar others is also an interrogation of self. It is humble to its core with a sincere desire to listen, understand, and act not just in terms of a single moral event but in an iterative fashion that co-creates self, other, and context. The hyperdialectic of care combines Nel Noddings’ (1984) notion of, “I am here for you” (p. 5) with a sense of wonder in the face of the world (Bannon, 2011, p. 328). The hyperdialectic acknowledges the physical and social location of the mind/body. Our positionality needs to be interrogated for its limitations of perspective and yet it provides a location from which care can flow. To summarize, the notion of the hyperdialectic of care is a method for living that acknowledges and supports our relational being. The next section addresses the dominant economic and political ideological operant today which appears to run counter to a caring relational ontology.

Neoliberal Precarity Liberalism is understood as a general political theoretical movement aimed toward individual freedom and democracy that has predominated modern Western thought. Striking an effective balance between freedom and social welfare has been a struggle for industrialized societies in the 20th and 21st centuries. The need to stimulate economies in the post-World War II era witnessed a wave of economic liberalization and another upsurge came in response to the stagflation of the 1970’s and 1980’s exemplified by the policies of Margaret Thatcher and Ronald Reagan. In reaction to these developments, neoliberalism has become a pejorative moniker utilized by those critical of current economic and political trends surrounding the power of capital (Thorsen, 2010, p.  188). The term neoliberalism is employed to

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describe both economic and political phenomena (Davies, 2014). In either case, the characterizations are similar. Anna-Maria Blomgren (1997) offers a representative definition: Neoliberalism is commonly thought of as a political philosophy giving priority to individual freedom and the right to private property. It is not, however, the simple and homogeneous philosophy it might appear to be. It ranges over a wide expanse in regard to ethical foundations as well as to normative conclusions. (p. 224)

Similarly, David Harvey (2005) describes neoliberalism as “a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets and free trade” (p. 2). Merleau-Ponty died prior to the term “neoliberalism”, but he did have much to say about liberalism that might be applied to today’s concerns about neoliberalism. For example, in lamenting the events leading to World War II, Merleau-Ponty (1945/2007) found the ideals of “liberty, truth, happiness, and transparent relations among men” desirable but lacking the “infrastructure to make them participate in existence” (p. 53). Sonia Kruks (1977) describes MerleauPonty as finding liberalism “formal, abstract, and divorced from social reality” (p.  398). For Merleau-Ponty, liberalism attempts to map general rational and abstract frameworks onto social and political phenomena that are embodied and ambiguous. In this manner, liberalism is too far removed from experience that is much better accounted for in a phenomenological and hyperdialectical approach. Unfortunately, neoliberalism has as its impact a precarious existence for many people. Some trace the increase in the use of the term “precarity” to the rise of global neoliberalism, particularly in the latter part of the 20th century (Lewis et al., 2015, p. 281) although we can find similar ideas in Marx (1978, pp. 294-438). Precarity is growing and inconsistently distributed to those who lack accumulated unearned privilege. This precarity can manifest in many ways including but not limited to contingent labor,  disproportional incarceration, less-than-meaningful work, labor

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exploitation, inhospitable behavior toward migrants and refugees, and inordinate concern for physical harm. For example, some theorists contend that the growing numbers of contingent migrant workers represent a separate working class whose experience of precarity makes it distinct from other working classes (Lewis et al., 2015, p. 584). Political theorist Isabell Lorey (2015) describes three dimensions of the precarious: precariousness, precarity, and governmental precarization (pp. 10-15). In Lorey’s lexicon, precariousness describes the fundamental vulnerability for which all living beings exist. Importantly for discussions of care ethics, Lorey describes precariousness as “always relational” as it is part of the shared human experience (2015, p. 12). For Lorey, precarity describes the ordering and distribution of precariousness in society (2015, p. 12). Governmental precarization covers a wide swath of lived experience, both economic and personal, as well as various forms of governing including formal political organizations and self-governing efforts (2015, pp.  12-14). Lorey argues that creating fear and vulnerability is actually an intentional strategy and instrument of neoliberal governing policy (2015, pp.  63-71). However, she finds in care and connection a potential resistant force to precarization: “I am interested in developing a political and social theoretical perspective that starts from connectedness with others and takes different dimensions of the precarious into consideration” (Lorey, 2015, p. 10). Lorey views neoliberal precarity as an “interruption” of our fundamental caring relationships (2015, p. 99). Neoliberalism can wreak havoc on the well-being of many people. Without romanticizing a time before the rise of neoliberalism or that simple material attainment or distributive justice can eradicate precarity, I want to suggest that a critical theory of care that includes the relational ontology offered by Merleau-Ponty can challenge the assumptions of neoliberalism. These assumptions include an extreme notion of autonomy and independence, an acquisitive and possessive disposition as well as the idea of freedom and liberty as absolute good. One of the challenges of neoliberalism is that many of its assumptions have wormed their way into common policy and practice as well as folk wisdom, as common sense.

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Liberalism, and by extension neoliberalism, draw on Enlightenment era valorizations of autonomy and independence. One result of this hyper individualization is a fragmented society marked by transitory associations as described by Lorey (2015). “It is not only work that is precarious and dispersed, but life itself. In all their differences, the precarious tend to be isolated and individualized, because they do shortterm jobs, get by from project to project, and often fall through collective social security systems” (p. 9). The notion of intersubjectivity and the ontological continuity of the flesh problematize the idea of autonomy and independence. For example, “rational self-interest” is a common-sense approach in discussing consumer behavior, voter behavior, business behavior as well as any number of social actions. However, if that “self” is reconceptualized as ontologically tied to others, then rational self-interest becomes rational shared interest. Accordingly, my significant decisions should take into consideration the care of other stakeholders, not because of an abstract moral motivation but because they are me. Although imperfectly so, I have the ability to cognitively and viscerally understand the precarity of others and I cannot hide behind a narrative that promotes the idea that everyone will be better off if I only act on behalf of myself. A truly relational ontology must conclude that I am not independent and I never was. Neoliberalism also favors an acquisitive disposition—both materially and socio-politically (Wilson, 2014). Not only is capital accumulation valorized but so are rights. Accordingly, the path to greater flourishing is through legally guaranteed privileges. Unfortunately, such possession or ownership is not a sufficient condition to realize the desired result. For example, the acquisition of civil rights may be an important milestone of personal voice and freedom but a law alone can never actualize the everyday experience of human freedom. However, a community committed to a hyperdialectic approach from a position of primary empathy is in a much better position to insure the flourishing of individuals. Life is not a zero-sum game to compete for acquisitions, material or otherwise. A relational ontology suggests that in acknowledging and accepting our intersubjectivity, we flourish in the well-being of others.

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Neoliberalism also places liberty as an ultimate good (Ives, 2015, p. 8). However, that liberty is usually understood as individual liberty: a desire to be free. A relational ontology as expressed in intersubjective identity suggests that liberty is not an absolute good. I do not want to be freed from the ties to my family, friends, community, society, but I want to flourish with them as part of my web of relationships. Absolute liberty is a myth and undesirable as incompatible with our fundamental connected being. In many ways, care is the antithesis of neoliberalism and a relational ontology reinforces the idea that we must find common cause in mutual well-being. Accordingly, the precariousness of others is my precariousness.

Conclusion: A Critical Theory of Care Reframes the Quest for Security The fact of embodiment and its ambiguities dispels the acquisitive myth of neoliberal security. No amount of acquired political rights, social privileges or economic wealth can prevent the ultimate death of the body. There is no fundamental external certainty or security. The quest for social justice can contribute to compassion and amelioration; however, the relational ontology of humanity points to relationships as the abiding solace in the face of ambiguity and uncertainty. Our love and care for one another, our memories, our collective embrace is the security that this existence has to offer. In a fitting article for The International Journal of Care and Caring, Joan Tronto offers a compelling analysis of humanity’s caring nature in service of a democratic form of care that challenges neoliberalism (2017). Tronto also provides a thorough critique of neoliberalism from a care perspective. In particular, she finds that within a neoliberal framework, care becomes dominated by economic concerns and therefore bounded by rationality, the market, and privatization. According to Tronto (2017), the message to individuals within a neoliberal ideology is: Care for yourself by acting rationally and responsibly; if there are care needs that you cannot meet for yourself, then use market solutions; and,

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finally, if you cannot afford market solutions, or prefer to care on your own, then enlist family (and perhaps friends and charities) to meet your caring needs. (p. 30)

Tronto describes this truncated care within neoliberalism as “unhealthy” (2017, p. 30) because it fails to recognize that humans are ontologically caring—homines curans. She calls for modern society to reorganize itself to place relationality, solidarity, and care at the center of political practices and behaviors as befitting our underlying caring selves. The application of Merleau-Ponty’s phenomenological approach to ontology supports Tronto’s conclusions and contributes a bridge between the personal and the political. Merleau-Ponty (1962) recognizes that political change alone, no matter how relational the narrative, must be accompanied by personal transformation and connection to be actualized through experience: “The world is not what I think, but what I live through. I am open to the world, I have no doubt that I am in communication with it, but I do not possess it; it is inexhaustible” (pp. xvi-xvii). As Kruks (1977) explains, for Merleau-Ponty “must become lived values, embodied in the structures of daily life and cease to be intellectual abstractions” (p. 398). Neoliberalism is insidious because of how this worldview has been internalized. If we simply regard what happened to Carlos Centeno as sad or unfortunate then we become victims of neoliberal hegemony as well and little has occurred to prevent the next such tragedy as we become complicit in neoliberal thinking. We must find Centeno’s story in ourselves and resolve to live in such a way as to care for one another, personally and politically. A method of living that can oppose neoliberal attempts to bound and limit care is the hyperdialectic: a search for understanding that connects as well as confronts. We must resist Walsh’s conclusion and creeping neoliberal hegemony of the personal and political. Accordingly, we should understand, empathize, and act to mitigate one another’s burdens and ameliorate society, not because of abstract rights or imposed moral duties but rather because of our shared being and flesh where empathy resides and can actualize caring action.

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Literature Bannon, B. E. (2011). Flesh and Nature: Understanding Merleau-Ponty’s Relational Ontology. Research in Phenomenology 41,327–357. Berman, M. (2003). The Hyper-Dialectic in Merleau-Ponty’s Ontology of the Flesh. Philosophy Today 47 (4), 404-420. Blomgren, A.-M. (1997). Nyliberal politisk filosofi. En kritisk analys av Milton Friedman, Robert Nozick och F. A. Hayek. Nora: Bokförlaget Nya Doxa.  Brubaker, D. (2006). Care for the Flesh: Gilligan, Merleau-Ponty, and Corporeal Styles. In D.  Olkowski & G.  Weiss (Eds.), Feminist Interpretations of Maurice Merleau-Ponty (pp. 229–256). Philadelphia, PA: University of Pennsylvania Press Canadian Council for Refugees. (2016). Migrant Workers: Precarious and Unsupported. Retrieved 23/5/2017 from http://ccrweb.ca/sites/ccrweb.ca/files/migrantworkers-2016.pdf Coole, D. (2007). Merleau-Ponty and Modern Politics after Anti-Humanism. Lanham, MD: Rowman and Littlefield. Crenshaw, K. (2011). Mapping the Margins: Intersectionality, Identity Politics, and Violence against Women of Color. Stanford Law Review 43 (6), 1241-1299. Dalmiya, V. (2002). Why Should a Knower Care? Hypatia 17 (1), 34–52. Daly, A. (2016). Merleau-Ponty and the Ethics of Intersubjectivity. London: Palgrave Macmillan. Davies, W. (2014). Neoliberalism: A Bibliographic Review. Theory, Culture & Society 31 (7/8), 309–317. Dillon, M. C. (1997). Merleau-Ponty’s Ontology, 2nd Edition. Evanston, IL: Northwestern University Press. Dillon, M. C. (1983). Merleau-Ponty and the Reversibility Thesis. Man and World 16, 365-388. Engster, D. (2007). The Heart of Justice: Care Ethics and Political Theory. New York: Oxford University Press. Hamington, M. (2004). Embodied Care: Jane Addams, Maurice Merleau-Ponty, and Feminist Ethics. Chicago, IL: University of Illinois Press. Hamington, M. (2015a). Performing Care Ethics: Empathy, Acting, and Embodied Learning. In J. C. Oxley (Ed.), Experiential Learning in Philosophy (pp. 52-64). New York: Routledge. Hamington, M. (2015b). Care Ethics and Confronting Intersectional Difference through the Body. Critical Philosophy of Race 3 (1), 79-100. Hamington, M. (2017). Empathy and Care Ethics. In H. Maibom (Ed.), The Routledge Handbook of Philosophy of Empathy (pp. 264-272). New York: Routledge. Harvey, D. (2005). A Brief History of Neoliberalism. Oxford: Oxford University Press.  Hass, L. (2008). Merleau-Ponty’s Philosophy. Bloomington, IN: Indiana University Press. Ives, A. (2015). Neoliberalism and The Concept of Governance: Renewing with An Older Liberal Tradition to Legitimate the Power of Capital. In S. Oueslati (Ed.), Who Governs in the Americas and In Europe. Mémoire(s), identité(s), marginalité(s) dans le monde occidental contemporain 14 (2), 1-15. https://mimmoc.revues.org/2263

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Johnson, G. A. (1999). In D. Okowski & J. Morley (Eds.), Merleau-Ponty, Interiority and Exteriority, Psychic Life and the World (pp. 25-34). Albany, NY: State University of New York Press. Kaushik, R.. (2013). Art Language and Figure in Merleau-Ponty. London: Bloomsbury. Kruks, S.. (1977). A Phenomenological Critique of Liberalism. Philosophy and Phenomenological Research 37 (3), 394-407. LaChance Adams, S. (2011). The Ethics of Ambivalence: Maternity, Intersubjectivity, and Ethics in  Levinas, Merleau-Ponty,  and Beauvoir  (Dissertation), University of Oregon. Lewis, H., Dwyer, P., Hodkinson, S., & Waite, L. (2015). Hyper-Precarious Lives: Migrants, Work, and Forced Labour in the Global North. Progress in Human Geography 39 (5), 680-700. Lorey, I. (2015). State of Insecurity: Government of the Precarious. London: Verso. Low, D. (1994). The Foundation of Merleau-Ponty’s Ethical Theory. Human Studies 17 (2), 173-187. Marratto, S. l. (2012). The Intercorporeal Self: Merleau-Ponty on Subjectivity. New York: State University of New York Press. Marx, K. (1978). Capital, Volume One. In Tucker, R. C. (Ed.), The Marx-Engels Reader 2nd Edition (pp. 294-438). New York: W.W. Norton and Company. (Original work published 1894) Merleau-Ponty, M. (2007). The War Has Taken Place. In T. Toadvine & L. Lawlor (Eds.), The Merleau-Ponty Reader (pp. 41-54). Evanston, IL: Northwestern University Press. (Original work published 1945) Merleau-Ponty, M. (2007). Epilogue to the Adventures of the Dialectics. In T. Toadvine & L. Lawlor (Eds.), The Merleau-Ponty Reader (pp. 293-317). Evanston, IL: Northwestern University Press. (Original work published 1954) Merleau-Ponty, M. (1962). Phenomenology of Perception (C.  Smith, Trans.). New York: Routledge. Merleau-Ponty, M. (1964). Eye and Mind (C. Dallery, Trans.). In J. M. Edie (Ed.), The Primacy of Perception and Other Essays on Phenomenological Psychology, the Philosophy of Art, History and Politics (pp. 159-192). Evanston, IL: Northwestern University Press. Merleau-Ponty, M. & Lefort, C. (Ed.). (1968). The Visible and the Invisible. Followed by Working Notes (A.  Lingis, Trans.).. Evanston, IL: Northwestern University Press. Merleau-Ponty, M. (1970). Sense and Non-sense (H.L.  Dreyfus & P.A.  Dreyfus, Trans.). Evanston, IL: Northwestern University Press. Morris, D. (2010). The Enigma of Reversibility and The Genesis of Sense in Merleau-Ponty. Continental Philosophy Review 43, 141–165. Morris, J. & Mitchell, C. (n.d.). Death of A Temp Worker. America Public Media. Retrieved 30/4/2017 from http://www.thestory.org/death-temp-worker Murrary, P. & Gillibrand, K. (2015). Contingent Workforce: Size, Characteristics, Earnings, and Benefits. U.S.  Government Accountability Office. Retrieved 30/4/2017 from http://www.gao.gov/assets/670/669899.pdf

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Noddings, N. (1984). Caring: A Feminine Approach to Ethics and Moral Education. Berkeley, CA: University of California Press. Noddings, N.(2010a). The Maternal Factor: Two Paths to Morality. Berkeley, CA: University of California Press. Noddings, N. (2010b). Moral Education and Caring. Theory and Research in Education 8 (2), 145–51 . Noddings, N. (2010c). Complexity in Caring and Empathy. Abstracta 5, 6–12. Nortvedt, P., Hem, M. H., & Skirbekk, H. (2011). The Ethics of Care: Role Obligations and Moderate Partiality in Health Care. Nursing Ethics 18 (2), 192–200. Olkowski, D. & Weiss, G. (2004). Feminist Interpretations of Maurice Merleau-Ponty. University Park, PA: Pennsylvania State University Press. Pettersen, T. (2011). The Ethics of Care: Normative Structures and Empirical Implications. Health Care Analysis 19, 51–64. Puig de la Bellacasa, M. (2017). Matters of Care: Speculative Ethics in More than Human Worlds. Minneapolis, MN: University of Minnesota Press. Putnam, H. (2004). Ethics Without Ontology. Cambridge, MA: Harvard University Press. Robinson, F. (1999). Globalizing Care: Ethics, Feminist Theory, and International Relations. Boulder, CO: Westview Press. Sevenhuijsen, S. (2000). Caring in The Third Way: The Relation Between Obligation, Responsibility and Care in Third Way Discourse. Critical Social Policy 20 (1), 5–37. Slote, M. (2007). The Ethics of Care and Empathy. New York: Routledge. Slote, M. (2010). Moral Sentimentalism. New York: Oxford University Press. Taminiaux, J. (1980). Merleau-Ponty. From Dialectic to Hyperdialectic. Research in Phenomenology 10, 58-76. Thorsen, D. E. (2010). The Neoliberal Challenge: What Is Neoliberalism? Contemporary Readings in Law and Social Justice 2 (2), 188-21. Tronto, J. C. (1994). Moral Boundaries: A Political Argument for An Ethic of Care. New York: Routledge. Tronto, J. C. (2013). Caring Democracy: Markets, Equality, and Justice. New York: New York University Press. Tronto, J. C. (2017). There Is An Alternative: Homines Curans and The Limits of Neoliberalism. International Journal of Care and Caring 1 (1), 27–43. Verducci, S. (2000). A Moral Method? Thoughts on Cultivating Empathy through Method Acting. Journal of Moral Education 29 (1), 87-99. Wilson, J. (2014). The Economics of Anxiety: Neoliberalism as Obsessional Neurosis. Retrieved from https://www.opendemocracy.net/openeconomy/japhy-wilson/ economics-of-anxiety-neoliberalism-as-obsessional-neurosis Zorn, E. (2017). Joe Walsh’s Tweets About Jimmy Kimmel’s Baby Shed Light On Health Care Debate. Chicago Tribune. Retrieved 3/5/2017 from http://www.chicagotribune.com/news/opinion/zorn/ct-kimmel-walsh-health-care-zorn-perspec0505-md-20170503-column.html

Phenomenology and Care: Reflections on the Foundation of Morality Per Nortvedt

There is reason to argue that care ethics is based on a specific human anthropology. Care ethics emphasizes the normative significance of human relationships and the crucial role that human character plays in moral agency. It portrays the human condition as relational and the human being as a relational being (Held, 2006; Noddings, 1984; Pettersen, 2008; Tronto, 1994). Interestingly, the way in which an ethics of care presents the basic foundation of morality has much in common with how human morality is portrayed in the moral phenomenology of Knud Ejler Loegstrup (1956, 1997), Edmund Husserl (1998) and Emmanuel Levinas (1991a, 1991b), to mention some phenomenologists who take ethics to be a crucial part of philosophy and epistemology. In this chapter I will critically elucidate the specific moral ontologies of phenomenology and care ethics and argue that in care ethics, compared to some phenomenological positions, there is a rather sparse understanding of the fundamental sources of human morality. Finally, I will discuss the relationship between moral ontologies and human character; how these foundational understandings of ethics (grounded in phenomenology and care) have relevance to phenomena within the fields of moral and social psychology. More specifically, I will examine how moral demands show up in intuitive and relational experiences.

Phenomenology and care ethics There are some fundamental similarities in how an ethics of care and phenomenological philosophy picture the foundation of morality.

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The elementary association between the two ethical perspectives is related to their portrayal of the origins of morality. In the phenomenology of Husserl (1998), Loegstrup (1956, 1997) and Jonas (1985), normative value is portrayed as an inborn, intrinsic feature of human existence, tied to a capacity of human nature to be intuitively responsive to value in the course of human experience. In care ethics, the ontology of care is mostly displayed by what several care theorists call a relational ontology. This relational ontology arguably sees persons embedded in relationships that have intrinsic moral value (Noddings, 1984; Pettersen, 2008; Held, 2006). Before making a comparison between the two outlooks, let us have a closer look at how moral value and the foundation of morality are viewed from these two perspectives, moral phenomenology and care ethics.

Phenomenology and the normative question Edmund Husserl, Knud Ejler Loegstrup, Hans Jonas and Emmanuel Levinas, as well as present day phenomenologists such as the Norwegian philosopher and nurse Kari Martinsen (2003a, 2003b), argue that there is an ethical demand showing up in human experience. This ethical demand can appear in the face of the Other (Levinas), in the sheer bodily vulnerability of a sick patient (Martinsen), or through the encounter with the uncontradictable need for protection and care of the newborn child (Jonas). The Danish theologian Knud Ejler Loegstrup theorizes human communication and the interhuman trust inherent in ordinary conversation. Loegstrup (1997) argues: Through the trust which a person either shows or asks of another person he surrenders something of his life to that person. Therefore, our existence demands of us that we protect the life of the person who has placed trust in us. (p. 18)

And further: By our very attitude to one another we help to shape one another’s world. By our attitude to the other person we help to determine the scope and hue of his world; we make it large or small, bright or drab, rich or dull, threatening or secure. We help to shape his world not by theories and

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views but by our very attitude toward him. Herein lies the unarticulated and one might say anonymous demand that we take care of the life which trust has placed in our hands. (p. 19)

Loegstrup’s claim is that communication presupposes some kind of mutual trust and common expectations of being heard and trusted. He focuses on communication, but the normative basis for the interhuman trust he finds in human communication is the same kind of receptivity and intuitively shared vulnerability that unites the other phenomenological positions, e.g. those of Levinas and Martinsen. I say intuitive and shared vulnerability because in phenomenology, human consciousness is understood primordially. This means that human consciousness is preconditioned by a non-interpretational and non-cognitive passivity, which alludes to what Husserl terms “impressional sense.” According to Husserl, consciousness does not merely have an active modality, in which it generates meaning and is engaged in reflective activity. Consciousness also has a capacity of being passive, hence a possibility of being affected and being open to normative experience.1 This is important, and as shown by Levinas in particular, the passivity of consciousness is a precondition for ethical receptivity, for being addressed by heteronomous experience.2 I will now elucidate this passive mode of consciousness in order to explicate its impact on normativity. In a broader picture of care ethics and phenomenology this is helpful when seeking to understand how a particular conception of human consciousness as being passive and modulated by impression can generate normative experience, experience of moral value. The receptive and passive character of consciousness is central to the possibility of an ethics, of ethical sensitivity. In particular, and as we shall see in the metaphysics of For a more detailed discussion of intuition and normative experience, see the next section on moral intuition and justification, as well as my elaboration of Lisa Tessman’s position (Tessman, 2015). 2 Levinas contrasts autonomous experience with heteronomous experience. Whereas autonomous experience is a type of experience that can be analyzed and comprehended, heteronomous experience is non-comprehensible, and cannot be subsumed under the cognitive capacities of the ego. 1

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Emmanuel Levinas, the recognition of specific features of human consciousness is crucial for understanding the foundation of morality.

Consciousness as non-cognitive and passive According to Edmund Husserl, intentionality is the way in which consciousness operates as an incarnation of meaning; how it always imbues phenomena with meaning, i.e. sees facts in the world as something. Consciousness is relational sui generis. When Husserl developed Brentano’s thesis of intentionality, it soon became clear to him that intentionality is the relational representation of the objective world by subjectivity. In other words, intentionality describes how the objective world primordially is related to subjectivity and how consciousness is representational, always conceptualizing and interpreting what is present to it. Human consciousness is the constant flux of a meaning-ascribing activity. In this way, a person’s perception of, for instance, his or her pain is always and intuitively a perception of the meaning of pain as a reflexive subjective experience. Pain is intuitively the experience of hurt, of painfulness. However, within the phenomenological tradition, consciousness is not merely understood by its intentionality; the pre-intentional characteristics of consciousness have been central as well. In the transcendental phenomenology of Husserl and in particular in Levinas’s ethics of radical otherness, consciousness is not merely active, reflective and interpretational. It also has a passive modality; there is a basic state of pre-intentional consciousness that is characterized by passivity and receptivity (Drabinski, 1999). This pre-intentional reflexivity which is characterized by sensibility is affective and non-thematic, non-cognitive and non-representational (Husserl, 1998; Levinas, 1991, 1992, 1998). The idea that perception and attentiveness are fundamental to an understanding of human consciousness also resonates with modern philosophy of mind (O’Shaugnessy, 2002; Zahavi, 2014, 1999; Barbaras, 2004; Waldenfels, 2004). In short, there seems to be a non-thematic, non-cognitive aspect of consciousness in which affect and impressional  sense play a central part. This kind of rudimentary sensibility,

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understood as a primary openness to the world, is crucial for the constitution of intentional consciousness: A sensibility that represents an immediate and affectively involved relation to the world is a precondition for active and interpretational consciousness. Sensibility and sensing is—according to Barbaras (2004)—a catching hold of qualities at the core of the world that is nevertheless not a mere apprehension of properties deprived of emotional impact. Sensing corresponds, in fact, to a mode of immediate communication, to sympathy with the world that does not entail any thematic dimension, i.e., any apperception or reflection on the side of the subject or any objectification on the side of the object (p. 220). Husserl recognized that consciousness contains a pre-reflexive passivity which precedes the reflexive intentional act (Husserl, 1998, pp. 9, 14). This also means that Husserl’s theory of intentionality in its broadest sense includes different attitudes of consciousness, theoretical as well as affective, and implies that the start of reflection presupposes Wahrnehmung, which is an intuitive and spontaneous experience of the object (Husserl, 1998, pp. 9, 14). In other words, “reflection is characterized by an articulation and thematization of something that existed in and for consciousness before reflection” (Zahavi, 1999, p. 131).

Intentionality and sensibility When Husserl articulated a non-theoretical and sense-forming preintentionality created by impression (Drabinskij, 1999), he said that this impressional sense or sense-forming intuition is prior to the reflexive act of consciousness: “Thus we arrive in each case at pre given objectivities which do not spring from theoretical acts but are constituted in intentional lived-experience imparting to them nothing of logo-categorical formations” (Husserl HUA IV 7). And further: we find those sensuous moments [pleasure, pain, tickle sensations are Husserl’s examples] overlaid by a stratum which, as it were, ‘animates,’ which bestows sense (or essentially involves a bestowing of sense)—a stratum by which precisely the concrete intentive mental process arises

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from the sensuous, which has in itself nothing pertaining to intentionality. (Husserl HUA IV 7)

Drabinskij (1999) claims that this peculiar sort of intuition grasps desire or sentiment as the feeling itself, and therefore does not grasp such modalities under the reflective activity of judgment. Reflective judgment is improper; it compromises the living immediacy of desire or sentiment. The reflective disposition fails to consider desire as desire, sentiment as sentiment. (p. 57)

Already in Logische Untersuchungen Husserl recognizes that consciousness derives from impression and develops his idea of phenomenological time as constituted by a primary impression, the now, a now which originates consciousness (Husserl, 1964). Levinas (1998) comments on this: The origin of all consciousness is a primary impression, an ‘Urimpression.’ But this original passivity is at the same time an initial spontaneity. (…) The mind is already free vis-a-vis its outflow. It is open onto the future through a protention—as Husserl calls it. Thus, time is not a form which consciousness assumes and that comes from the outside. It is truly the secret of subjectivity itself, the condition for a free mind. Like intentionality directed upon a transcendent object, time expresses freedom itself. (p. 77)

Consciousness—from passivity to normativity It is a very intriguing and interesting question, how, according to this specific phenomenological approach, human consciousness, being modulated by impression and being passive, can generate normative experience, experience of moral value. Noteworthy, this experience of value is what phenomenologists emphasize when they claim that an ethical demand emanates from the face, from bodily vulnerability signified in the human encounter, or in the course of human conversation. The crucial question here, which goes to the heart of moral philosophy as such, is this: When it comes to this ethical demand elucidated by phenomenologists, what, simply speaking, is its origin? In my view, there are two primordial questions of moral epistemology to be answered. First, how can moral value be conceived in

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the first place, if it is not cognitive, i.e. represented in reflective consciousness? Second, how can one conceive of a pre-reflexive intentionality that at the same time becomes the origin of an ethical sensibility and responsibility?

The ethical metaphysics of Emmanuel Levinas In order to understand the shift from a particular view of phenomenal consciousness to an understanding of ethical experience, I believe it is necessary to turn to Levinasian metaphysics. Levinas discovered the idea in Husserlian phenomenology of a pre-intentional sense, named by Husserl “axiological intuition” (Drabinskij, 1999), and developed this idea of impressional sense into an ethics. Husserl’s main concern was to understand the enigma of subjectivity and how subjectivity as intentionality is a manifestation of how knowledge is relationally constituted. In the ethics developed by Levinas, the infinite particularity and incomprehensibility of the other person (the Face) is the sovereign source of subjectivity, obligation and hence humanity. Furthermore, Levinas argues that on the whole ethics breaks with Husserl’s thesis of intentionality. Levinas’s idea is that the encounter with human vulnerability surely calls for reflection, but reflective intentionality is always too late on the scene. When reflection starts, what motivates reflection has already ceased to exist temporally. In the words of Dan Zahavi: “Thematizing erlebnis originates before the moment I focus my attention” (Zahavi, 1999, p. 132). For Levinas, the ethical incident of being shaken, the Urimpression, cannot be conceived as a pre-reflective act, and neither as a movement within consciousness. Early in his commentary on Husserl’s Ideas II, Levinas discovers the potential for developing this Husserlian idea of a primal impressional sense into an ethics. According to Levinas the character of value comes from a specific attitude of consciousness, of a non-theoretical intentionality, simply irreducible to knowledge and cognition altogether. Levinas detected a Husserlian possibility of an ethics which could be developed beyond Husserl himself (Drabinskij, 1996).

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While for Husserl the primal impression is retrievable within the retentional-protentional flow of consciousness, Levinas locates the ethical impression outside the living present. Ethical sense is anterior to retention and hence pre-phenomenal. The primary impressional sense of otherness is always absent, it is rendered present only through a trace. “The relation or passivity is prior to and constitutive of the phenomenal relation that structures and makes possible the initial presentational clue” (Drabinski, 1999, pp. 201-202). As Husserl himself claims in Ideas II, in its primal functioning the sensation affects the Ego as foreign and is thereby fundamentally and originally pregiven. The affecting moment of the sensation precedes its givenness (Hua IV, p. 336/348). The givenness of the primal sensation in lived-experience is then merely a clue to what has already passed. The possibility of a language for describing this “already passed” is to be found in the phenomenological reflection on time and genesis and this is the problem to which Levinas turns. Husserl addresses the issue of which part of lived experience that has ethical significance. According to Levinas, however, ethics as an experience of otherness, of alterity is a peculiar sort of Wahrnemungen irreducible to experience, an experience that is outside experience, i.e. alien to consciousness itself. This is where Levinas breaks with Husserl. Husserl always sees the experience as well as the non-thematizing, nonreflective act of consciousness prior to the reflective act, but still it is conceived as a part of intentionality. Levinas, on the other hand, places the ethical experience of otherness outside intentionality per se. “Ethics is what grips hold of you, without the source of this impression ever can be a mode of representation, a theme” (Levinas, 1996). According to Levinasian metaphysics, it is through an investigation of this relation between the primary pre-intentional impression and intentionality that ethics must be understood (Drabinskij, 1999).

The primordiality of the ethical sense In The Possibility of Altruism (1978), Thomas Nagel argues that normative experience is first and foremost located in what he called a “pained awareness” of the suffering of another as a reason for “you”

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to help him (p. 43). However, he never tracks the sources of this idea of a pained awareness outside reflective reasons. Consequently, he never managed to answer the normative question properly, since ethical experience is an awareness that is not located in ordinary human reason and experience. Nagel’s investigation of altruism can only be properly addressed through an understanding of primordial and non-cognitive awareness. One way to phrase Nagel’s question phenomenologically is the following: It is not because you understand what it means for another person to have pain that you are pained by his pain. Painfulness comes as a suffering for the other’s suffering that is non-cognitive, pre-reflective and affective. The feeling of pain you experience due to the pain of another person’s body does not represent an activity within reflective consciousness. It is first and foremost a pain evoked in the subject by the pain of the other person. You can never be alerted by the pain of another person if his pain does not affect you in a pre-reflective sense. Levinas would say that the emotional upheaval caused by the pain of another reflects a passive consciousness, laid open to an assignation. This passivity of consciousness is the birth of ethical responsibility. It is a passivity which welcomes the other person into the domain of morality. Levinas’s bold claim is that ethics cannot be reduced to comprehension (Critchley, 2002). Here, we have the idea that when consciousness is affected, the source of affection cannot in any way become a representation. How is this possible? Levinas speaks about a peculiar form of human experience which is not an autonomous experience but instead a heteronomous experience. In a heteronomous experience, the  content of the experience is not known to the subject, it is not shaped by the subject’s intentional efforts (Drabinskij, 1999). It is an experience of radical alterity, or what Levinas in later works also calls “radical absence” (Drabinskij, 1999). But how can the other person be approached by a subject if the affection is not knowledge, not a part of epistemology, not representable within consciousness, not a theme? How can the encounter with the other person become an ethics if this otherness is incomprehensible?

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In this context it is essential that Levinas names otherness “infinity”, and later, in Otherwise than Being and Beyond Essence, “vulnerability” (Levinas, 1991b). Levinas has recourse to an idea of infinity in Descartes’, third meditation (Levinas, 1991a). According to Descartes we have in infinity an idea that exceeds the thought that thinks it. To think infinity is to think the unthinkable. Descartes locates the sources of infinity in God (as it is only a divine person who can have placed this thought of infinity in the human person). According to Levinas, to encounter the face is to encounter alterity, a particularity that escapes comprehension completely. To see a face is to encounter infinity. The face is more than the nose, the expression in the eyes, the wrinkles on the forehead. It is more than the totality of its expressive parts. Instead, it is a phenomenon of pure expression that overwhelms consciousness. In Levinas’s words, “it is a power without power” (1991a). The nakedness of the face, its expression of vulnerability shatters the subject, makes the I vulnerable to the other’s vulnerability. The face creates an impression of infinity, a manifestation of responsibility which is not assumed by cognition. One can never fully comprehend what tells us to be responsible for the other person. This experience of alterity, of the Other’s, otherness, is for Levinas an experience that has radical implications because it means the dethronement of egoism. The imperialism of the Ego is rejected. The ethical impression, the encounter with the Other, cause consciousness and egoism to step down. The I is paralyzed, passive, addressed, accused (Levinas, 1991a). The only way to know the always incomprehensible otherness of the Other, is by taking responsibility for him or her. Ethics is the awakening of subjectivity in the absence of interpretational consciousness. Through the “Here I am, take care of me,” the subject becomes an I. Subjectivity is born of responsibility. For Levinas, ethics is when the subject loses its grip on the world, being appealed to by the Other. Ethics is the awakening of consciousness in the concrete experience of vulnerability. Ethics is the traumatic revival of a consciousness not longer for itself, but before the Other. Alfonso

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Lingis says in the foreword to Otherwise than Being and Beyond Essence (Levinas, 1991b) that ordinarily “the sensibility affected by alterity is not that sensibility, where identification is already at work. Precisely alterity is the unidentifiable. Its sense is the unilateral direction of an approach, caught in a being ordered, an obedience” (p. xviii).

Sensibility and vulnerability In later works Levinas articulates sensibility in a non-ontological and expressive language. He tries to describe the non-objective, nontheoretical and affective aspects of ethics. He seeks to articulate the ethical saying, the non-thematizable event of being in a movement from oneself to the Other, of being shaken without the source of affection ever becoming a theme for conceptualization. Ethics is to be vulnerable for the suffering of another, his naked skin, his destitution. Ethics traumatizes the consciousness of the Ego, and when it awakes, speaks about a time before its existence. In the ethical encounter the human subject is accused by the other, assigned by him, responsible beyond imagination, even for his own responsibility. Levinas speaks about the birth of subjectivity, in which the sensible subject is awakened before the Other. We have here the idea that ethical subjectivity as responsibility for the Other is composed by the exposed and vulnerable body and the singular materiality of the face of the other (Drabinskij, 1999, p. 213). Recent thinkers find in the Levinasian idea of vulnerability to the other person a primordial ethical sense which is located in a non-verbal language of bodily expressions (Levine, 1999; SchefflerManning, 2001). Levine (1999) says: What I think he means is that obligation first takes hold of us bodily—in the flesh—in a time that is, at each and every moment, i.e., both synchronically and diachronically, prior to thematizing consciousness, prior to reflective cognition, and therefore prior to the ego’s construction of a worldly temporal order. (p. 279)

The ethics of Levinas is concrete with regard to how it locates the moral imperative in the corporeal expressions of vulnerability, the

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nudity of human destitution displayed in the eyes of the human other. Levinas argues that ethics actually locates the moral imperative, the imperative of unconditional moral value, in sensibility: a sensibility awakened by an alterity which appears in the concreteness of the Other’s face, which nonetheless is an expression not of finitude but of infinity. It is essential to say that the ethics of Levinas isn’t psychologically founded nor is it an articulation of moral reasons. Rather than seeking an ethics, it seeks the meaning of ethics (le sense de l’éthique). Levinas’s ethics does not focus on how moral consciousness relies upon a direct perception of value as in empathic perception (Vetlesen, 1994) or how the moral imperative is discovered within the constraints of human reason. It rather seeks to discover the sense of ethics in how human consciousness when encountering the infinite meets the limits of reason, of its representational imperialism. Hence, ethical receptivity is born. But how can ethics originate outside the scope of human reason when the Other, not as a concept or a theme but as an enigma, shatters the Ego and subordinates it to a position of infinite responsibility for the other person? The answer is primarily that cognition and reason as dominating and controlling forces of human consciousness, in always trying to reduce all otherness and infinite particularity to conceptual understanding (what Levinas names “the Same” or “Sameness”) is called into question. To “reduce the Other to the Same” is to obfuscate particularity and emphasize generality, comparison, it is to totalize the other person, reducing him or her to one among the many. The Face of the human Other cannot be reduced to conceptual categories; it can only be comprehended as obligation and hence as responsibility, as ethics. This is the fundamental core of a Levinasian ethics. And Levinasian ethics makes it possible to argue that the enigma of ethics is care itself. For instance, nursing care is a concrete manifestation of being vulnerable to another person’s vulnerability. To be affected by another’s subjectivity as a condition for understanding the nature of his experience is the issue here (Nortvedt, 2001). I have showed elsewhere how the clinical encounter is moralized by the actual encounter

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with human vulnerabilities; how awareness of a patient’s pained body is itself a vulnerability, a vulnerability that modifies and humanizes the clinical medical encounter (Nortvedt, 2012). Touching an injury does not merely cause the senseless and distant reflection upon destroyed and bleeding tissue. More profoundly it is an affection, revealing ethical significance. The inhibition present in the skillful touch of the nurse who dresses the wound is an ethical inhibition which says: “Do not hurt, be careful! Do not cause unnecessary pain!” There is a phenomenological background for ethical responsibility in the way the nurse clinician is emotionally touched by the reality of the patient’s condition (Nortvedt, 2001, p. 25). In hospital care, the patient’s subjective experience is in many cases not seen as an independent factor of influence to medical treatment. There seems to be a reduction of subjectivity to measurable signs, discrediting the validity of subjective experience. The medical objectification of illness tends to discard subjective experience as a valid reason for care and treatment and as an ethical reason in itself. This understanding, of subjectivity as vulnerability, as a sensibility in which you are shattered by the other’s vulnerability and try to comprehend and accept his subjectivity, is what Levinas seeks to establish as the foundation of ethics. It is through the definite affection for the particularity of the Other that ethics is born. In nursing care, we see this as the primary normative fact of the clinical experience. When you are shaken by the stiffness of an aching body, when you are worried about the redness of a wound or excited by the joy of recovery: In this movement through different clinical experiences which affect you not merely as pathophysiological facts but as tangible vulnerabilities, nursing care is shaped and the clinical encounter becomes a palpable awareness of the Other’s humanity. This affective intentionality is what initiates the moral predicament of the clinical relationship in health care. It is also this bodily felt sympathy and upheaval that spontaneously induces so much of the intuitive carefulness and attentive behavior which is so crucial to good nursing care. Moreover, it is this affective awareness, which Levinas calls the rupture of the subject’s equilibrium, passivity,

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wakefulness and vertigo induced by emotion, that on so many occasions qualifies the clinical sense and originates the really significant and also knowledge-based clinical observations. Emotion puts into question not the existence, but the subjectivity of the subject; it prevents the subject from gathering itself up, reacting, being someone. What is positive in the subject sinks away into a nowhere. Emotion is a way of holding on while loosing one’s base. (Levinas, 1992, p. 121)

Care ethics and ethical metaphysics The ethical metaphysics revealed by phenomenology is principally a specific theory of pre-intentional consciousness where affective intuition plays a crucial role. Secondly, in the various phenomenologists’ accent on ethical experience, a most powerful perception of our moral foundation is to be found. How does this picture of our moral basis fit into the basic normative assumptions of care ethics? Are there any similarities, any points where contact and mutual inspiration between the two ethical outlooks (phenomenology and care ethics) is possible? Care ethics aspires to be a much broader theory than the normative perspectives accentuated by phenomenology and ethical metaphysics. Moral phenomenology seeks primarily to understand moral sensitivity as primordial and fundamental to the human condition. Care ethics, emanating from the psychologically inspired perspectives of Carol Gilligan and further developing into its current and mature shape as an ethical theory (Held, 2006; Pettersen, 2008; Tronto, 1994), aspires to be a full-fledged normative theory based on a particular moral psychology. Care ethics is not constrained by the limits of metaethics. However, this taken for granted, care ethics is also based upon strong metaethical assumptions. Many care ethicists argue that its perspective embodies a specific relational ontology and a conception of normative conflicts where understanding the normative affiliations between people play a central role (Noddings, 2003; Held, 2006; Pettersen, 2008). Care theories argue that relationships to other people

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constitute our self-understanding and common humanity. Accordingly, an ethics of care claims that all humans are interdependent, that we are born into relationships we have never ourselves chosen. Relationships are sources of vulnerability and dependency. They can fail, they can even be oppressive, but they are also prominent channels through which we can shelter and protect our common human vulnerabilities. To care for one another and to live in a web of significant relationships are essential parts of human flourishing. Some care theorists also argue that our earliest relationships shape our moral development, and our fundamental capacities of empathy and concern for the other person (Held, 2006; Slote, 2007). A perspective that has contributed most to an understanding of the ontology of care is to be found in the early theories of Nel Noddings (1984). Noddings focuses on natural care and the rudimentary impulse to care for the other and encounter the world through relationships of receptivity, nurture and protection. This ideal of ethical caring is in Noddings’s view constituted by the best of our initial experiences of being “a one-caring and the one-cared for”: There is, however, a fundamental universality in our ethic, as there must be to escape relativism. The caring attitude, that attitude which expresses our earliest memories of being cared for and our growing store of memories of both caring and being cared for, is universally accessible. (Noddings, 1984, p. 5)

As compared to moral phenomenology, mainstream care ethics does not embody a philosophy of consciousness as a basis for its metaethical assumptions. Its moral ontology and its conception of normativity build on suppositions about relational affiliations as the basis for moral responsibilities. An ethics of care emphasizes connectedness, dependency and vulnerability as essential normative features, and this is possibly its most important contribution as a normative theory. It foregrounds relational networks. Moral agents have responsibilities towards particular human beings with whom they are affiliated and who are affected by the moral agents’ actions. In this regard, care theories have much in common with debates about the normative value of relationships in modern analytical philosophy (Scheffler,

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2002, 2012; Williams, 1981; Blum, 1994; Nordhaug, 2017). However, strangely enough, care ethicists rarely address the vivid debate about relationships and moral responsibilities in mainstream analytical moral philosophy. If the ontological primacy of relational interdependency should be a hallmark of an ethics of care, its normative implications should be more extensively elaborated upon. Arguing for the normative significance of relationships inevitably raises questions about partiality, in other words the unequal distribution of care on the basis of favoring the interests of particular people. What also follows from a relational view is that people are not considered to have rights independent from the web of relationships which they are a part of. In an ethics of care, where so much emphasis is put on relational bonds and attachments to other people, a kind of partiality is apparently favored and care ethicists should take a stand in debates between partialists and impartialists in ethics theory and practice. In its relational ontology, care ethics mainly factors out human relatedness and the value of empathy and human affectedness as an important part of moral agency. Nonetheless, care ethics scarcely addresses the challenges that derive from its normative emphasis on relational attachments (Nortvedt, Skirbekk, & Hem, 2011). Some intuitions which have to do with the normative value of human relatedness are central to care ethics. This question about partiality has been heavily debated in moral theory, but mainly as a critique of deontology and consequentialism. Although impartiality means to universalize one’s moral commitments, giving equal consideration to the interest of all relevant parties, partiality means to attach a disproportionate significance to one’s own relationships, preferences and commitment, simply because they are one’s own. Moreover, phenomenological ethics and Levinasian metaphysics trace the sources of normativity to a specific notion of pre-reflective and pre-intentional human consciousness. It could be interesting to examine how the particular moral intuitions illuminated by phenomenology and care ethics can be understood within the conceptual framework of current analytical ethics and empirical psychology.

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Hopefully, thereby one can get a better grip on the foundation of morality and our most basic moral intuitions of responsibility and not to hurt the other person. I will now turn to Lisa Tessman’s work on moral intuitions and moral dilemmas in her recent book Moral Failure (2015), as she provides a—to my mind—necessary and realistic basis for moral intuition in psychology.

Moral intuitions and moral justification What is apparent is that while care ethics locates the moral demand of responsibility in human interdependency and interconnectedness (what care ethicists call a relational ontology), Levinas tries to answer the most profound questions about the metaphysical reality of ethics. For centuries, moral realists have struggled with questions about the objectivity or subjectivity of values, and realists have insisted on the existence of values that are independent of subjective experiences, reflective consciousness and human intentionality altogether (McNaughton, 1988; Korsgaard, 1996). Moral realists commonly endorse what I will call justificatory realism. This is a realism that defends the existence of moral truths, i.e. objective answers to what is right or wrong, independent of individual cognition and evaluations (Nortvedt, 2012). But such a realism about moral truths relies on a particular moral ontology. The most profound ontological question about moral value is the claim that moral properties exist as part of the fabric of the world itself, and that ethical justification takes at face value a set of intuitions that reflect the existence of these moral properties (Darwall, 1983). In the first part of this chapter I investigated the fundamental ontology and metaphysical basis for morality, and showed that in care ethics there is a vagueness when it comes to arguing for the fundamental sources of relational value. In fact, care theories do not really illuminate what a “relational ontology” pertains to in its deepest normative sense (Nortvedt, Skirbekk, & Hem, 2011). The clue here is that care ethics, as well as Levinasian ethical metaphysics, draw attention to some moral intuitions not to harm, not to kill, and speaks positively of securing the well-being of the other person. Most eloquent is the Levinasian phenomenology of the

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Face that utters the command of non-violence and not killing the other person. In comparison, the voice of Nel Noddings looms large when she maintains the obligations of the one-caring on behalf of the one-cared for. However, these moral intuitions of care and to protect the other person, as portrayed by care ethics, do not have a proper philosophical and psychological grounding. This despite the fact that care ethics itself was initialized at the psychology department of Harvard University through the works of Lawrence Kohlberg and Carol Gilligan (Nortvedt, 1996). Levinasian ethics, on the other hand, accompanied by the ethics of phenomenologists like Hans Jonas, K. E. Loegstrup and E. Husserl when underlining the ontology of the ethical demand, miss a proper backing in moral psychology. In my view, a theory of value must in its deepest essence be backed by a realistic theory of moral motivation. The most profound intuitions to respond to moral demands cannot be totally disconnected from an empirical basis of human psychology. In the following I will sketch a valid picture of the psychological basis for moral intuitions as presented in the works of American philosopher Lisa Tessman. Lisa Tessman distinguishes between two distinct cognitive systems of moral judgments; “an automatic intuitive system that produces most of our moral judgments, and a controlled reasoning system that can be, though usually is not, engaged in the production of moral judgments” (Tessman, 2015). This controlled system is what usually is involved in reflection, or what Lazarus calls “cold cognition” (Lazarus, 1994). These two systems of cognition, one intuitive and “hot” (Lazarus’s term) and one cold, together comprise the preconditions for and the productive event of ethical reflection. In Tessman’s words this is the “dual process theory” of moral judgments which is also based on a “multi-systems moral psychology” (Tessman, 2015, p. 57). Tessman’s leading aim is to provide a rationale for the most deeply embedded and affect-based moral intuitions that frequently are involved in prohibitions against hurting, demeaning and killing other people. Her defense of our most intuitive moral sensibilities resonates profoundly with a Levinasian conception of ethical vulnerability.

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Furthermore, this defense of moral intuitions also reminds us about the primacy of care and non-violence, as well as the emphasis on non-hurting and relational/proximity-based responsibilities portrayed in care ethical positions (Nordhaug & Nortvedt, 2011). What is most fascinating about Tessman’s analysis of moral judgments, is that she clarifies the rationale of what she names “unavoidable moral demands” without mystifying these situational demands that are frequently present in moral encounters (Tessman, 2015). She values the normative independence of situational, intuitive and immediate moral appeals, originating from our emotional evaluations, rather than cognitive representations that appear when we reflect upon particular situations. And, using the work of another philosopher and psychologist, Tamar Gelder, as a basis, she calls these normative appeals aliefs as opposed to the cognitivist conception of beliefs. According to Gelder (2010), who introduced the concept, an alief is to have an innate or habitual propensity to respond to an apparent stimulus in a particular way. It is to be in a mental state that is associative, automatic, and arational. As a class, aliefs are states that we share with non-human animals; they are developmentally and conceptually antecedent to other cognitive attitudes that the creature may go on to develop. Typically, they are also affect-laden and action generating. (p. 288)

According to Tessman, some of these aliefs also have intrinsic normative value. For instance, the value of not killing an individual is a sacred value, a value that cannot easily be traded off by other values. Even if killing one person would produce net benefit for others and saving a greater number of lives, a sacred value, according to Gelder and Tessman, cannot be totally discredited by cognitive deliberation. This does not mean that it is always morally impermissible to take a person’s life, but it means that killing always has a moral cost, there is always a problem attached to killing. Usually, such an act of violating the rights of and hurting another person is phenomenologically to strive against something intrinsically good, of value. In Nagel’s words, it is to “swim against the normative current” (Nagel, 1986,

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p.  45). One has done something intrinsically wrong for a greater good. And as we shall see, not only from philosophy, but also from research in empirical psychology, killing another person is never an act that can be totally traded off by particular consequentialist calculations. Typically, many of the intuitions illuminated by Tessman’s examples cannot be eliminated for maximizing purposes. They are nonconsequentialist. One such example is envisioned in the classical Trolley dilemma. In the Trolley case, an empty runaway trolley is headed down a track on which five people are trapped. However, by flipping a switch you can divert it onto a sidetrack on which only one person is trapped. The question is; should you flip the switch if this is the only way to stop the trolley from running over the five people? Then there is a variation of the dilemma in which the same trolley is heading down the track towards the five people, but there is no switch, only a very heavy person, you can push over the footbridge to stop the train and save the five others. Should you do it? (Tessman, 2015, p. 66).

It is interesting indeed that most people would choose the switch alternative to save five others, but they would not push or seriously hesitate to push the one person to death in order to save five other people. It seems that intuitively, people are acting from a deontological restriction against killing (in Tessler’s own words showing an intuitive emotion) based on prohibition in the Push case, while on a consequentialist view in the Switch case. Why is this so? How is it that ethical consequentialism that is so rationally pervasive at the same time is built on an implausible and unrealistic moral psychology? Ethical consequentialists would obviously discard these intuitions not to harm for the greater good, holding them to be conservative as they in the end obviously would have as a consequence the overall harm of a larger number of persons. The problem is how to ground what Samuel Scheffler calls “agentcentered prohibitions.” How could one defend a position that would produce net benefit for all, or in Scheffler’s (1994) words: For how can it be rational to forbid the performance of a morally objectionable action that would have the effect of minimizing the total number

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of comparably objectionable actions that were performed and would have no other morally relevant consequences? How can the minimization of morally objectionable conduct be morally unacceptable? (p. 244)

The argument from Tessman and Gelder is that the prohibition against killing can never be fully rationalized. This prohibition will always stand out as protecting a sacred value, a value that cannot be traded off for maximizing purposes. The point is that maximizing rationality is not always at issue in the case of grounding certain normative and affect-based moral intuitions. Tessman and Gelder argue that there are different emotional responses at work in intuitive and impulse-like “do not harm” or “do not kill”-responses, compared to responses involved in consequentialists trade-offs. For instance, moral psychologist Joshua Greene calls intuitive emotional responses “alarm-bell emotions” whereas responses that can be traded off are called “currency responses”: “Alarm-bell emotions are designed to circumvent reasoning, providing absolute demands and constraints on behavior, while currency emotions are designed to participate in the process of practical reasoning, providing negotiable motivations for and against different behaviors” (Cushman, Young, & Greene in Tessman, 2015, p. 71). The point of significance in the works of Gelder, Greene and Tessman is that moral intuitions function as prohibitions against harming other persons. Our intuitive sacred values are not the result of a rational and fully reasoned process, but rather the product of intuitive emotional responses that are highly situational and personal. According to Tessman, “alarm-bell responses will be felt wrong no matter what reason tells” (Tessman, 2015, p. 73). Furthermore: In rationalist moral theories, the absence of justifying reasons is sufficient to warrant the disqualification of a judgment as normative or prescriptive. However, it is common to experience intuitive moral judgments as normative or prescriptive regardless of the fact that they come without justifying reasons. What, then, takes place in the process of making an intuitive moral judgment to convey to the subject a sense of moral requirement? (Tessman, 2015, p. 75). This important point made by Tessman deals profoundly with the question of moral motivation. Remember Thomas Nagel’s formulation

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in his The Possibility of Altruism about “the pained awareness of another person’s suffering as a reason for alleviation” (Nagel, 1978). My question was, and still is: How can it be that this “pained awareness” incurs a reason to help by relieving a person’s pain? Tessman’s argument here (and I agree) is that an emotion or a specific situational desire is not sufficient for moral prescriptivity. Intuitions must be accorded with a certain form of anguish or guilt to be normatively prescriptive (Prinz, 2007). One must feel obliged to act in the sense that not acting would incur a cost, in the form of guilt or anguish: “Calling a prescriptive sentiment an ‘oughtitude’ makes it clear that what is crucial for prescribing is not the feeling of wanting or desiring to do something, but rather the feeling that one ought to do it” (Prinz, 2007, p. 262). This claim of Prinz about the normative “ought” is important, but it does not answer the question: Why should one refrain from harming a person for the sake of a greater good? The idea of prescriptive sentiments does not answer the basic question about the origin of an “ought” in the first place. And the origin of a moral demand (“tan ought”) is a deeply rooted metaphysical question, a question that even Kant leaves open in the end of the Groundwork of the Metaphysics of Morals (1964). In my view, only a Levinasian turn in ethics gives a plausible attempt to answer this question, an answer that is not rooted in a particular religious world view. This question about the origin of moral responsibility is a question about the primordiality of morality, a question most fully addressed by Levinasian metaphysics, outlined in the first part of this chapter. Tessman (2015) asserts: I am suggesting that reasoning has its own pitfalls and that intuitive processing plays an irreplaceable role in human morality: there are some values that people have sacralized and thus marked as infinitely significant, their sacrifice unthinkable ; upholding these values can only be accomplished intuitively, for reasoning ruins them and disqualifies the reason from the relationships whose core they form. (p. 97)

And this is where the notion of moral intuitionism becomes important; the idea that even in situations where ethical reflection would disqualify our intuitions, it would be right to act from our intuitive

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alarm-bell responses which express these same sacred values (Tessman, 2015; Greene, 2008). Which values are Tessman referring to? How can she say that reason ruins and disqualifies the agent-centered and proximity- and carebased value? Moreover, what is the essence of the “oughtitudes” which emanate from relationships and human bonds? First and foremost, Tessman talks about non-consequential values, values of protecting the life of one person even if doing so might jeopardize the personal interests and integrity of others. At focus is the classical example from Bernard Williams, in which three people are in a boat that is about to sink. One of the people is your wife, and the question is: Is it permissible to save one’s wife just because it is one’s wife? In this case, Williams’s famous formulation of “one thought too many” is brought to mind: “This construction (that a moral principle can legitimate the permissibility of saving one’s wife on the cost of disregarding others m.i.) provides the agent with one thought too many: it might have been hoped by some (for instance, by his wife) that his motivating thought was that it was his wife, not that in situations of this kind it is permissible to save one’s wife”. (Williams, 1981, p. 18)

Williams’s point is not merely about the meaning of motivation; that it is right to be so motivated as to have the wellbeing and rescue of one’s wife as an overriding consideration above other need-based, deontological or consequentialist considerations. It is also his point that some considerations “are external to morality”, i.e. they should not stand up to the test of moral principles or judgments at all. Even if there might be good prima facie arguments for not saving one’s wife but the strangers instead because they outweigh in number, it would still be right to shelter a sacred value based upon the alleged normative significance of human relationships. Williams is mistaken, however, if he thinks that relational reasons are external to morality. The “ought” which is expressed in the intuition not to hurt another person or to protect one’s dearest attachments is deeply rooted in the metaphysics of moral responsibility. This metaphysics was outlined in the previous chapter, hence illuminating the Levinasian position.

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Conclusion Both phenomenology and care ethics shed light on some inexplicable and uncontradictable moral demands associated with human proximity and relational attachments. Both positions take human relationships to have normative value in the sense that moral responsibility is a response to situations of vulnerability, suffering and destitution. But, as we saw in the previous chapter: While phenomenology offers a metaphysical and epistemological explanation of relational normativity which includes the moral demands also associated with spatial and temporal closeness, care ethics only merits normativity on the basis of solid relationships founded on human attachments (Held, 2006; Noddings, 1984). Care ethics’ way of delineating normativity relies on some strong assumptions about the normative significance of relationships and obligations to people based upon one’s personal attachments. However, their arguments for the substantial normative nature of these obligations are not convincing. A metaphysical basis for the sources of morality is necessary in order to confirm the normative claim of care ethics about its relational ontologies and the intrinsic value of care and relationships (Held, 2006; Noddings, 1984). The crucial issue from the perspective of phenomenology as well as care ethics, is that they both as ethical perspectives situate normativity not in impartial reason, but in relational and affective, intuitive experience. The contribution of Tessman and empirical work from moral psychology is to qualify these intuitions as valuable in their own right, and to give them credit as genuine sources of moral beliefs that can withstand rational scrutiny. In fact, they argue, these intuitions are sacred and have “an irreplaceable role in human morality” (Tessman, 2015). But the normative sacredness of moral intuitions by Tessman can best be understood within a phenomenological and, in the end, metaphysical framework of morality.

References Barbaras, R. (2004). Affectivity and Movement: The Sense of Sensing in Erwin Strauss. Phenomenology and the Cognitive Sciences 3 (2), 215–228. Blum, L. (1980). Friendship, Altruism and Morality. London: Routledge & Kegan Paul.

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Critchley, S. (2002). Cambridge Companion to Levinas—Introduction. Cambridge: Cambridge University Press. Darwall, S. (1983). Impartial Reasons. Ithaca, NY: Cornell University Press. Drabinskij, J. (1999). Sensibility and Singularity. Albany, NY: State University of New York Press. Held, V. (2006). The Ethics of Care – Personal, Political. New York: Oxford University Press. Husserl, E. (1964). The Phenomenology of Internal Time – Consciousness. Bloomington & London: Indiana University Press. Husserl, E. (1998). Ideas Pertaining to a Pure Phenomenology and to a Phenomenological Philosophy (2nd book). Boston, MA: Kluwer Academic Publishers. Jonas, H. (1985). The Imperative of Responsibility. Chicago, IL: Chicago University Press. Gendler, T. S. (2010). Intuition, Imagination and Philosophical Methodology. Oxford: Oxford University Press. Greene, J. (2008). The Secret Joke of Kant’s Soul. In Sinnot-Armstrong, W. (Ed.), Moral Psychology, Vol 3: The Neuroscience of Morality (pp.  35-79). Cambridge, MA: MIT Press. Kant, I. (1964). Groundwork of the Metaphysics of Morals. New York: Harper Torchbooks. Korsgaard, K. (1996). The Sources of Normativity. Harvard: Harvard University Press. Lazarus, R. (1991). Emotion and Adaption. Oxford: Oxford University Press. Levinas, E. (1991a). Totality and Infinity (3rd ed.). Boston, MA: Kluwer Academic Publishers. Levinas, E. (1991b). Otherwise than Being or Beyond Essence (2nd ed.). Boston, MA: Kluwer Academic Publishers. Levinas, E. (1992). The Theory of Intuition in Husserl’s Phenomenology. Evanston, IL: Northwestern University Press. Levinas, E. (1998). Discovering Existence with Husserl. Evanston, IL: Northwestern University Press. Levine, D. M. (1999). The Philosopher’s Gaze—Modernity in the Shadows of Enlightenment. Los Angeles, CA: University of California Press. Loegstrup, K. E. (1956/1997). The Ethical Demand. Notre Dame, IN: Notre Dame University Press. McNaughton, D. (1988). Moral Vision. An Introduction to Ethics. Oxford: Basil Blackwell. Manning, Scheffler R. J. (2001). Beyond Ethics to Justice. Through Levinas and Derrida: The Legacy of Levinas. New York: Franciscan Press. Martinsen, K. (2003a). Fra Marx til Loegstrup: Om Etikk og Sanselighet i Sykepleien [From Marx to Loegstrup: on ethics and sensibility in nursing] (2nd ed.). Oslo: Universitetsforlaget. Martinsen, K. (2003b). Fenomenologi og omsorg [Phenomenology and Care] (2nd ed.). Oslo: Universitetsforlaget. Nagel, T. (1978). The Possibility of Altruism. Princeton, NJ: Princeton University Press.

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Nagel, T. (1986). The View from Nowhere. Oxford: Oxford University Press. Noddings, N. (1984). Caring—a Feminist Approach to Ethics and Moral Education. London: University of California Press. Nordhaug, M. (2017). Partiality and Justice in Nursing Care. London: Routledge. Nordhaug, M., & Nortvedt, P. (2011). Justice and Proximity: Problems for an Ethics of Care. Health Care Analysis 19 (1), 3-14. Nortvedt, P. (1996). Sensitive Judgment—Nursing, Moral philosophy and an Ethics of Care. Oslo: Tano Aschehoug Press. Nortvedt, P. (2001). Clinical Sensitivity—The Inseparability of Ethical Perceptiveness and Clinical Knowledge. Scholarly Inquiry for Nursing Practice 15 (1), 25–45. Nortvedt, P. (2008). Sensibility and Clinical Understanding. Medicine, Health Care and Philosophy 11 (2), 209-219. Nortvedt, P. (2012). The Normativity of Clinical Health Care: Perspectives on Moral Realism. Journal of Medicine and Philosophy 37 (3), 277-294. Nortvedt, P., Skirbekk, H., & Hem, M. H. (2011). The Ethics of Care: Role Obligations and Moderate Partiality in Health Care. Nursing Ethics 18 (2), 192-200. O’Shaugnessy, B. (2002). Consciousness and the World. Oxford: Oxford University Press. Pettersen, T. (2008). Comprehending Care: Problems and Possibilities in the Ethics of Care. Plymouth: Lexington Books. Prinz, J. (2007). The Emotional Construction of Morals. New York: Oxford University Press. Scheffler, S. (1994). The Rejection of Consequentialism. Oxford: Clarendon Press. Scheffler, S. (2002). Boundaries and Allegiances. Oxford: Oxford University Press. Slote, M. (2007). The Ethics of Care and Empathy. New York: Taylor & Francis. Tessman, L. (2015). Moral Failure. On the Impossible Demands of Morality. Oxford: Oxford University Press. Tronto, J. (1994). Moral Boundaries. London: Routledge. Vetlesen, A. J. (1994). Perception, Empathy and Judgment. An Inquiry into the Preconditions of Moral Performance. University Park, PA: Pennsylvania State Press. Vetlesen, A. J. & Jodalen, H. (1992). Closeness, an Ethics. Oslo: Norwegian University Press. Waldenfels, B. (2004). Bodily Experience Between Selfhood and Otherness. Phenomenology and the Cognitive Sciences 3 (3), 235–248. Williams, B. (1981). Moral Luck. Cambridge: Cambridge University Press. Zahavi, D. (1999). Self-Awareness and Alterity. Evanston, IL: Northwestern University Press. Zahavi, D. (2014). Self and Other: Exploring Subjectivity, Empathy and Shame. Oxford: Oxford University Press.

SECTION II: Phenomenology and care

Sovereignty and the Ethics of Pathos Gernot Böhme

Being Sovereign The concept of sovereignty has its origins in constitutional law. It should not be overlooked, however, that “sovereignty” has long since been adopted into the German language in general and that in everyday usage it means a character trait or a certain quality of action. We would thus call a person’s confident appearance a souveränes Auftreten or say that someone accepted defeat souverän, that is, graciously. “Being sovereign” also means to be above the things, but not in such a manner that they do not concern one, but rather that one is able to cope with them. In my book Anthropologie in pragmatischer Hinsicht [Anthropology from a pragmatic point of view]1 I drew on this everyday usage and proposed the concept of sovereignty as an ideal of self-cultivation of the human being—in opposition to the traditional concept of autonomy. This shall be discussed below and the consequences for ethics drawn. The core point is that the ethics of acting as it has existed up to now has to be supplemented with an ethics of pathos. First of all, however, I would like to explore sovereignty as a concept of constitutional law, because another, very influential philosophical concept of sovereignty is derived from it, namely Georges

Gernot Böhme. (1985). Anthropologie in pragmatischer Hinsicht. Frankfurt am Main: Suhrkamp. 1

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Bataille’s.2 This is, as shall be shown, diametrically contrary to my understanding of sovereignty as an ideal for humanity. Constitutional law distinguishes between internal and external sovereignty. External sovereignty means the authority of a state to regulate its affairs independently of others and to act as an independent power vis-à-vis other states, whether as a contracting party or as an enemy in war. Inner sovereignty amounts to supreme or absolute power. Understanding the state as sovereign is a consequence of secularization; previously, for the most part before the seventeenth century,3 supreme power was derived from religious authorities—the divine right of princes, which in Germany lasted up to the nineteenth century, was a memento of this thought. The internal sovereignty of a state means that it both enacts and enforces the law. This dangerous union of legislative and executive power can of course be used by governments for totalitarian rule. That is why modern, that is, republican states have introduced the principle of the division of powers. Furthermore, democracies are characterized by the principle of popular sovereignty according to which sovereignty is only temporarily delegated to governments and these governments are accountable to the people: “All state authority is derived from the people.”4 Bataille has turned the constitutional concept of sovereignty into an ethical concept according to which the individual person should understand himself as the king in an absolute state. Bataille’s concept of sovereignty is an enhancement of Kant’s concept of autonomy: autonomy is opposed to heteronomy. According to Kant, the person is his or her own lawgiver and therefore, in order to preserve him- or herself, he or she must resist all outside determination and heteronomy. However, for Kant autonomy of the person is anything but arbitrariness of the individual. Georges Bataille. (1956). La souverainité. Monde nouveau, 101–103. Souveränität und Subversion: Georges Batailles Theorie der Moderne. Munich: Matthes & Seitz.Rita Bischof. (1984). 3 The concept was elaborated in theory by Jean Bodin in his Methodus ad facilem historiarum cognitionem (1650, reprint: 1967, Aalen: Scientia-Verlag), but it was not until the French revolution that it became significant in practice. 4 Basic Law for the Federal Republic of Germany, Article 20, 2. 2

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The empirical person is free and autonomous when and insofar as he or she behaves according to the categorical imperative, that is, assesses his or her maxims according to whether they are suited to become a universal law. Hence, the individual human being is autonomous only as a rational subject and autonomy is from the outset related to the universal, that is, to the possibility of society. This means that the autonomous person has to control his or her individual urges and inclinations, which in terms of personal development means that his or her self-will has to be broken. Bataille rightly notes that the individual is then anything but sovereign. Rather, he or she is subject to a multitude of heteronomous dictates—from social practices through laws to strictly effective but unwritten taboos. His doctrine of sovereignty can be understood in the sense that he wants to assign self-determination to the individual as an individual, while Kant only conceded the individual self-determination as a general subject. The outcome is that according to Bataille sovereignty manifests itself less in limitation by self-imposed rules than in the rupturing of externally determined barriers, including the limits of reason. This thought is related to the late Victorian phenomenon that pleasure results not so much from satisfying desires, but rather from violating prohibitions that set barriers to desires. Thus, according to Bataille, sovereignty is experienced as a pleasurable transgression of prohibitions. Bataille’s concept of sovereignty is thus a radicalization of the Kantian concept of autonomy: the self-determination of the subject becomes unbounded. De Sade and the Libertines were among the forerunners of this provocative thought; considering that it was very important at a certain stage, it is quite regrettable that as a result the concept of sovereignty has been philosophically discredited. It is now all the more necessary to restate the concept of sovereignty with reference to everyday speech. This everyday speech is clearly related to the notion of a ruler. However, it draws from this idea features which have nothing to do with reigning, much less with commanding, but rather are derived from the prominent position and a certain inviolability of the sovereign. The sovereign is also a human being, but he can more readily afford certain human weaknesses and even mistakes than can others because his position protects him from being challenged because of them. In his

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studies on courtly society, Norbert Elias showed that the sovereign and the nobles were able to display a certain immodesty towards the subjects, especially with regard to their human, all-too-human qualities.5 Things are similar when in German you say that an ordinary person is sovereign. His reputation does not depend on whether he has a stain on his suit, he will be able to afford to have a bad day occasionally, he will be able to accept an awkward situation, endure frustration and admit to a mistake. His consciousness of self is not compromised by faults, mishaps, errors and other untoward incidents.6 What is more, it consists precisely in the fact that he is aware of his dependency, fallibility, his frailty as a human being. In contrast, a person whose consciousness of self is based on autonomy must be shaken by the smallest incidents of external determination. Kant’s admonition about alcohol consumption is well known: “the limit of self-possession can easily be overlooked and overstepped.”7 A consciousness of self based on autonomy is in a theoretical perspective an illusion and in a practical perspective highly unstable. It overlooks the condition humaine, in particular the bodiliness of human existence. By contrast, sovereignty is characteristic of a consciousness of self in which the pathic manners of existence are recognized and integrated into the self-conception of the human being.

Being Given to Oneself In philosophical anthropology, Heidegger may well have been the first to integrate the pathic modes of existence into the essence of 5 Norbert Elias. (1983). Die höfische Gesellschaft. Untersuchung zur Soziologie des Königtums und der höfischen Aristokratie. Frankfurt/M.: Suhrkamp. [Norbert Elias. (1983). The Court Society (E. Jephcott, Trans.). Oxford: Blackwell.] 6 For a positive turn on Freud’s concepts of repression and regression and the recognition of not being master in one’s own house, see my essay: “Obliques Denken” [Oblique thought], (2003), in: B.  Boothe and W.  Marx (Eds.). Panne – Irrtum – Missgeschick. Die Psychopathologie des Alltagslebens in interdisziplinärer Perspektive [Mishap – mistake – misfortune. The psychopathology of everyday life in interdisciplinary perspective], Bern: Huber, pp. 177–185. 7 Immanuel Kant. (1798). Anthropologie in pragmatischer Hinsicht. In W. Weischedel (Ed.). (1963). Werke in 6 Bänden (Vol. VI, p. 470 (A 72)). Darmstadt: Wissenschaftliche Buchgesellschaft.

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man—he calls them existentials. The term he uses to designate this is thrownness. The human being finds itself as something thrown into the world. The interpretation of thrownness as an existential, that is to say as a possibility of being, conceals the negativity of the experience somewhat, the experience of feeling thrown. It becomes clear when we look at what it is about: One finds oneself as a human being equipped with a body, assigned to a sex, endowed with a certain constitution, shaped by a mother tongue, as a member of a family and a people. None of this is by choice, it is given to one, one is given to oneself as a person who is determinate in a certain way. The Heideggerian term facticity is more apt for this aspect of thrownness: these are primarily facts, which are of course also possibilities, but which actually limit the possibilities of self-design. With Foucault we should speak of dispositifs. Being given to oneself means above all that one experiences oneself as nature. Our own body is the nature that we are ourselves. However, we experience the fact that we are nature not only as facticity, but rather in the form of bodily urges, that is, time and again as something that happens to us. For this reason, we also encounter ourselves as a spontaneity, but this is exactly what we, as a conscious ego, in the first place and in general are not. For this reason it is appropriate to speak in this context of pathic manners of existence: We are body primarily inasmuch as we are subject to our nature. Objectively speaking, corporal urges result from the organic character of our body. This includes our sexuality. We find ourselves as members of the male or female sex. Now it is rightly said that the experience of being a boy or girl, man or woman, is primarily the attribution of social roles. But the real hard point lies in the fact that our body is given to us through its urges in a sex-specific manner. This also means that in our bodily, physical development we experience a certain biographical pattern that is simply sex-specific. For this reason, Ute Gahlings validly spoke of sexual biographies.8 It may well be even more Ute Gahlings. (2006). Phänomenologie weiblicher Leiberfahrungen [Phenomenology of female experiences of the body]. Freiburg: Alber. 8

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important for our self-givenness as a sexual being that the bodily urges that make us feel our sex come upon us from the opposite sex or in looking at the opposite sex. If and to the extent that is the case, it means that we have to understand ourselves as part of humanity, as Aristophanes explains love in Plato’s dialogue Symposium: love is the longing for the other half.9 The sovereign human being will therefore understand his or her sexual aspect in terms of relationality. This human being is what it is not in itself, but in relation to the other; hence it is not self-sufficient, but rather dependent on other people not only in its subsistence but also in its essence, its being what it is. Self-givenness is something that happens to us to a particularly high degree in pain and disease. These pathic manners of existence are characterized by the fact that they thrust themselves upon me unavoidably as mine. No matter how strange the feelings may be, how contrary to what a person as a conscious ego actually wants and thinks of him- or herself, they imperatively assert the claim that they concern me. I therefore speak here of concerned self-givenness and have already identified it as a source of self in another chapter of this book.10 Sovereignty therefore means above all a consciousness of self that is mindful of nature in the subject, that is, recognizes the body as the origin of the self. This results in a certain calmness towards bodily urges, at least in the sense that they are not experienced as an impairment of self-certitude or self-possession, as Kant says. Dependence on other people, which occurs particularly in the case of illness, does not have to be hurtful, but can be welcomed as an opportunity to be cared for.11 Care itself must not necessarily be understood as a mere substitution of self-care,12 Plato astutely included homoerotic pairs in this model. “Eingedenken der Natur im Subjekt” [Mindfulness of nature in the subject]. 11 In comparison with the European attitude, the Japanese attitude is completely different: it is not characterized by the compulsion to be independent. See: Takeo Doi. (1993). Amae. Freiheit in Geborgenheit. Zur Struktur japanischer Psyche (4th ed.). Frankfurt/M.: Suhrkamp. [Takeo Doi. (1973). The Anatomy of Dependence (J. Bester, Trans.). Tokyo: Kodansha International.] 12 This is how Dorothea E.  Orem defines it in her influential book: Nursing. Concepts of Practice (2001, 6th ed.). St. Louis, Mo, London: Mosby. 9

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but rather can be understood as solidarity in bearing the burden of existence. Furthermore, I am given to myself in that I feel this way and that. The feeling can be generated by endogenous impulses, as in the case of pain, but in most cases it is due to the impressions that touch me from my surroundings or to the impositions made on me by my fellow human beings, and more generally by social conditions. Hermann Schmitz speaks in this context of situations in which I am embedded. The crucial point for our context is that I experience myself in my feeling as given to myself by my environment. Feeling is also a pathic manner of existence—it happens to me. Therefore, for the self-conception of the person as an autonomous subject, feelings and moods and what we call emotions must be impairments. Of course, even the sovereign human being cannot simply surrender to the impressions and impositions that impinge on him, he would be ripped apart as Orpheus was by the women. He will, however, respect them as ways in which he is given to himself because they are what makes the world relevant to him and makes an authentic participation in other people and natural and social conditions possible. Finally, I am given to myself by the contingent events of the course of my life. Although as an organic process life has its own cycle and as a whole is a metamorphosis from birth to death, it is only in the rarest of cases that it can be understood in the way the German novel of development had it, namely as an emergence and the maturation of an entelechy. Rather, what I experience as my life is determined to a large extent by contingency, that is, by the people I have met, the constellations in which I have got involved, by the events in which I have participated, and the fates, for example the diseases, that I have received. In recognition of this contingency of the own biography, the sovereign person will not define himself as being outside of his own circumstances as the autonomous person does, but will instead retain an existential fidelity to what has touched him and to those whom he has met, because he knows that it is they who constitute his substance. On the other hand, we will not call a person sovereign who simply affirms the situation in which he finds himself

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as his destiny, as Martin Heidegger and Gottfried Benn, for example, emphatically declared their fidelity to their people: “... but I personally declare myself in favor of the new state, because it is my nation that is making its way here.”13 Criticism and resistance are also a possible way to recognize the contingency of the situation in which one finds oneself.

Ethics of Pathos Inasmuch as we are accustomed to refer ethics to the area of action and decisions, the demand for an ethics of the pathic seems strange, and not only at first sight. Rather, we wonder what we are supposed to be able to do with regard to what is given to us, what touches us. Is not the pathic by definition beyond my influence, so that it does not matter how I react to it? I have myself as I am given to myself, and what is supposed to strike me strikes me. At first glance, the argument for the pathic seems to be something of a moral relief: There are many things in my life that I do not have to ascribe to myself because they are situations about which I cannot do anything and circumstances into which I simply slipped somehow. It can sometimes even be recommended as a moral relief to accept what befalls us as contingent—for example when it is important not to make a disease more burdensome by ascribing the blame for it to oneself.14 In the previous section I wrote quite airily that the sovereign person understands his body as the source of his self, lives through his situation as his substance, keeps faith with the contingencies that impinge on him, knows himself in his sexuality as part of a whole, considers the world’s impressions and impositions to be relevant to him: but all of this does not just happen by itself. Rather, sovereignty Gottfried Benn to Klaus Mann in 1933, quoted here from “Doppelleben” [Double life] in Gottfried Benn. (1961). Gesammelte Werke in vier Bänden [Collected works in four volumes] (Vol. IV, p. 78). Wiesbaden: Limes-Verlag. [Translator’s note: The “new” state is the German Reich under the National Socialist dictatorship after the Nazi seizure of power in 1933.] 14 Farideh Akashe-Böhme und Gernot Böhme. Mit Krankheit leben [Living with disease], a.a.O. 13

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is an attitude that must be acquired and defended against other trends and fashions, and which must ultimately be enacted against culturally entrenched prejudices. To represent the latter, I have repeatedly pointed out the opposition between the ideal of sovereignty and the ideal of autonomy. An ethics of the pathic is not quite as strange in the Christian West as it seems at first sight. After all, the Man of Sorrows is the figure that displays exemplary humanity here. Christian culture involves a positive turn on suffering. Of course, it cannot be said that Jesus has to be followed in the sense that ordinary people should be expected to take on the suffering of others. In the imitation of Christ, however, acceptance of suffering, humility and submission have become a moral topos. In Buddhism suffering also plays a major role as the basic character of life, but it is not given a positive turn. Similarly, the special respect that Christianity pays to the poor and sick is also not found there. It is precisely in this respect that Christian culture differs from its Graeco-Roman predecessors in Europe. Since suffering for others has become completely incomprehensible in Christianity, let me discuss a case of voluntary suffering that is closer to us: the poet Ernst Wiechert. Wiechert was an author of humanistic origins who was much read at the time; it has to be recognized that under the Nazis he voluntarily had himself taken to a concentration camp. After the submarine commander and clergyman Martin Niemöller had been convicted because of his resistance to the Nazi regime and had served his prison sentence and been released, he was put into a concentration camp by the Nazis. This affair so outraged Wiechert and made him so desperate about what made up the public sphere and the state at the time that, as he wrote, there was nothing left for him to do but to stand on the side of those who are suffering. “Then Johannes [his pseudonym in Der Totenwald (The forest of the dead)] recognized that he would be destined to suffer with this head.”15 He therefore wrote a letter to the National Socialist Ernst Wiechert. (1957). Wälder und Menschen. Eine Jugend [Forests and people. Youth]. In Ernst Wiechert. Sämtliche Werke in zehn Bänden [Complete works in ten 15

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party in which he stated that in future he would no longer participate in general donation campaigns, but rather would send everything that he could spare to Niemöller’s family. He was aware that the consequence of this letter would be that the Gestapo would come to get him. That was what then happened and he spent—after some time in prison—three months in the concentration camp Buchenwald. It  cannot really be said that Wiechert was a resistance fighter. A fighter tries to harm the opponent, he is willing to take risks, but will try to avoid his own suffering. In the case of Wiechert, by contrast, we encounter the paradigmatic case of a person who believes that he can only preserve his own moral integrity by willingly accepting suffering. In doing so, he not only set an example for the moral selfimage of the Germans, but also for an ethics of the pathic. It could be that in moral behavior the point is sometimes not action at all, but rather the willingness to suffer. It could be said that sovereignty presupposes as a basis an initiation in the willingness to suffer. Suffering must not necessarily be understood as enduring pain, but rather in a much more general sense that something happens to us. In our time an initiation in the corresponding behavior is needed because life in the present day is planned as much as possible, in part by reason of our technical infrastructure and in part by reason of our achievement orientation, and because this planning aims at security. To the extent possible, nothing is supposed to happen. In the context of this general tendency of the modern person to make him- or herself inviolable, sovereignty would not even have a slim chance. But since the human being is inevitably afflicted by misadventures, illness and misfortune, such happenings come upon him or her unprepared. Thus, sovereignty more generally presupposes a willingness to submit so that the human being is trained in accepting outside determination. volumes] (Vol. 9). Munich: Desch. Includes: Der Totenwald. Ein Bericht 1939 [The forest of the dead. A report], p. 206. [He speaks of “this head” because in the book the unnamed clergyman appears to Johannes in his dreams as a face with an indistinct body, sometimes only as a face.]

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This requires a form of self-care that does not manipulate the own body, training and functionalizing it to achieve maximum performance, but rather treats it with a certain respect. The bodily urges that arise from it are in relation to my ego a kind of outside determination, but they still belong to me. Therefore, the ethics of the pathic requires that one should train an attitude towards life in which I recognize myself in my bodily urges as myself. The willingness to allow something to happen to one is a basic attitude of an ethics of the pathic, and this willingness is all the more in demand in the case of illness. As has already been suggested, the ethics of being ill does not at all consist in moralizing the disease. On the contrary, what is required is that we come to terms with contingency: At some time it strikes everyone, and there is no point to quarrelling with fate. Moreover, the point is not to reject the fact of being affected, which is manifested especially in pain, but to recognize it as a confirmation of subjectivity: It is about me. Finally, disease is the paradigmatic situation in which the person can experience his or her dependence on others. In principle this dependence is also given in other circumstances, but it is suppressed by the ideology of independence or obscured by market mechanisms and the like. In contrast, the ethics of illness turns out to be the postulate that we can be ill, that is, able to surrender ourselves to the care of others and to feel at ease in their care. In cases of illness, the idea of the sovereign human being is closely related to the demand to be a self-responsible patient. In particular, what is expected of the patient, namely to cooperate in therapy decisions, requires a high degree of willingness to take risks—and thus also a willingness to suffer. Just like the tendency to avoid suffering at all costs, yielding to the physician’s decisions without question also leads to a dependency on the machinery of the health system. For the sovereign person it is clear that every therapy decision is also a decision on how and as what kind of person he or she wants to live, so that this decision cannot simply be entrusted to the expert alone. There is another element of Christian culture to which the ethics of the pathic can be linked, namely the commandment to love our

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neighbor. This commandment has always been plagued by two paradoxes that make it incomprehensible. First of all, can something like love be commanded? Love is an affect, something pathic—but that means either it strikes you or it does not. There is nothing that can be done here. The second paradox is that we should love our neighbor as ourself. Now love of oneself is a highly doubtful matter and it would not cast a good light on love of one’s neighbor if it was oriented to self-love. My interpretation, which I first presented in Anthropologie in pragmatischer Hinsicht [Anthropology from a pragmatic point of view],16 resolves the paradoxes as follows: The commandment of love of the neighbor does not require us to have an affect, but rather not to suppress the natural participation in the suffering of others. Natural participation is based on resonance or mimesis, at any rate a perception through inner understanding by reenacting. Everyone is equipped with this manner of perception from an early age; without it it would not be possible to understand expression—which is already relevant in communication with the mother— and even language learning would be impossible. What the commandment of love of the neighbor actually requires is to let this inner understanding through reenacting take effect and thus to suspend the coolness that is habitual among us, the coolness with which we fend off affective participation. Furthermore, the commandment of love of the neighbor does not refer to self-love, but actually says: love your neighbor as yourself. It is thus actually the demand to let solidarity take effect on the basis of a sympathetic perception of the suffering of the other. To be in solidarity with the other means to let yourself be affected by what affects him or her.17 We have thus identified another basic requirement of the ethics of the pathic. In general, it requires us to develop in ourselves the ability to love. In the most general sense, this means opening ourselves to being affectively touched by the other. This requirement presupposes Anthropologie in pragmatischer Hinsicht, op. cit. (see footnote 1), p. 107. On this definition see my book Briefe an meine Tochter [Letters to my daughter] (1995, p. 129). Frankfurt/M.: Insel. 16 17

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the basic possibility of affective participation, but demands, in opposition to the remoteness that has become habitual in technical civilization and our achievement-oriented society, that we sumit to the other as well as to images and situations. It should not be concealed that this can only be possible in part and that the individual must also protect him- or herself from what is called overstimulation. But it is precisely because this is the case that the demand for openness to affective touching takes shape. What is primarily required in order to be able to love is not the ability to act, but much more fundamentally the ability to let oneself be touched by the other. This also has consequences for love in the usual sense, for erotic love. Our view of this love is obscured to a great degree by the dominance of the active manners of being in our culture. Accordingly, love is understood on the basis of the assumption of a desire, and the ability to love would then be the art of satisfying this desire as effectively as possible. But love cannot be made. After all, it presupposes very fundamentally that we are affected by the other person, that this other person addresses, stimulates and sparks us. For this reason the genuine art of love is the ability to let oneself go, and then it is not so much an act as a going along with the suggestions that arise from the affection of others.

Conclusion The ideal of sovereignty has a great appeal for many and is certainly superior to the traditional ideal of autonomy, which dominates European ethics to this day. But make no mistake about the fact that, like autonomy, sovereignty cannot be attained effortlessly, and that being sovereign requires no less self-cultivation than autonomy. Just as the ethics of action belongs to autonomy, sovereignty involves the ethics of the pathic. A consciousness of self in the sense of sovereignty is characterized by a high degree of stability. According to everyday [German] usage, the sovereign person is the one who stands above things, and in terms of the ethics of the pathic negative points such as mistakes, setbacks, impairments due to physical frailties do not shake his or her consciousness of self. The reason for this is that he views such negativity as belonging to himself, and can even use it as an opportunity for self-examination.

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Because he experiences his body and the urges that arise from it as the source of the self, his self-relationship can be described as holistic. This means that his internal order is less marked by constraints and oppression than in the case of the autonomous human being. His life is not so much determined by restrictions, rather it is rich in content due to his openness and willingness to participate. But, as already pointed out, this does not come about automatically. Like autonomy, sovereignty is not a natural talent. Rather, it presupposes self-cultivation in the sense of an ethics of the pathic. This means, first and foremost, the willingness to submit and let something happen to one. The sovereign person is aware that in what he is, he is dependent on his body, the others and the circumstances. This willingness to be given to oneself constantly requires the difficult balance between losing oneself and preserving oneself. This wording, however, is still derived from the idea of autonomy, according to which—as we brought to attention in the Kant quotation—in preserving itself the self is constituted against losing itself. For the sovereign person, however, the point is to find oneself even in losing oneself, more generally in submitting, in letting oneself be given to oneself. In a paradoxical way, this turns even what happens to the person into something the person has to be able to do. The ethics of the pathic is essentially an art of letting oneself go. For this reason it involves, in addition to being able to love and being able to tolerate frustration, also the ability to suffer, to be ill, to grow old. This requires a reconciliation with the finiteness of human existence, with the ephemeral character of human existence. Whereas the autonomous human being, as in particular Kant’s philosophy makes clear, is still determined by other-worldly hopes, finding his or her dignity in a transcendental existence,18 namely as an intelligent See on this point my paper: “Zwischen Aufklärung und Gegenaufklärung: Kants Religionsschrift” [Between Enlightenment and Counter-Enlightenment]. (2005). In  Susanne Dungs & Heiner Ludwig (Eds.), profan – sinnlich – religiös. Theologische Lektüren der Postmoderne. Festschrift für Uwe Gerber [profane – sensual – religious. Theological readings in Postmodernism. Festschrift for Uwe Gerber] (pp. 227-238). Frankfurt/M.: Peter Lang. 18

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subject, sovereign existence is characterized by radical worldliness. What constitutes human existence must not only be borne somehow or other, it must be borne well.

References Bataille, G. (1956). La souverainité. Monde nouveau, 101–103. Rita Bischof. (1984). Souveränität und Subversion: Georges Batailles Theorie der Moderne. Munich: Matthes & Seitz. Benn, G. (1961). Gesammelte Werke in vier Bänden [Collected works in four volumes] (Vol. IV, p. 78). Wiesbaden: Limes-Verlag. Gernot Böhme. (1985). Anthropologie in pragmatischer Hinsicht. Frankfurt am Main: Suhrkamp. Böhme, G. (1995). Briefe an meine Tochter [Letters to my daughter]. Frankfurt/M.: Insel. Böhme, G. (2003). Obliques Denken. [Oblique thought]. In: B. Boothe and W. Marx (Eds.), Panne – Irrtum – Missgeschick. Die Psychopathologie des Alltagslebens in interdisziplinärer Perspektive [Mishap – mistake – misfortune. The psychopathology of everyday life in interdisciplinary perspective], (pp. 177–185). Bern: Huber. Bodin, J. (1967). Methodus ad facilem historiarum cognitionem (1650, reprint: 1967, Aalen: Scientia-Verlag). Doi, T. (1993). Amae. Freiheit in Geborgenheit. Zur Struktur japanischer Psyche (4th ed.). Frankfurt/M.: Suhrkamp Elias. N. (1983). Die höfische Gesellschaft. Untersuchung zur Soziologie des Königtums und der höfischen Aristokratie. Frankfurt/M.: Suhrkamp. [Norbert Elias. (1983). The Court Society (E. Jephcott, Trans.). Oxford: Blackwell.] Gahlings, U. (2006). Phänomenologie weiblicher Leiberfahrungen [Phenomenology of female experiences of the body]. Freiburg: Alber. Kant, I. (1798). Anthropologie in pragmatischer Hinsicht. In W.  Weischedel (Ed.). (1963). Werke in 6 Bänden (Vol. VI, p. 470 (A 72)). Darmstadt: Wissenschaftliche Buchgesellschaft. Orem, D. (2001). Nursing. Concepts of Practice (6th ed.). St. Louis, Mo, London: Mosby. Wiechert, E. (1957). Wälder und Menschen. Eine Jugend [Forests and people. Youth]. In E. Wiechert. Sämtliche Werke in zehn Bänden [Complete works in ten volumes] (Vol. 9). Munich: Desch.

Ethics in a Quandary Gernot Böhme

Suffering Becomes the Central Category Contraceptives make a new sexual ethics necessary; world peace requires an extraordinary moral effort; the possibilities of technology demand an ethics of the technical world. While these desiderata have been regularly proclaimed for many years now, while it has been generally acknowledged that such demands were justified first in view of the atomic bomb and since then with regard to the environmental catastrophe, there has been no progress in the definition of a new ethics, and indeed it seems that even what ethics was about has been obscured. Obscurity is then suspected of obscurantism, indeterminacy has the taint of irrationality. This has brought discredit on ethics as such. It is a matter for young Christian women and gossiping aunts, an anachronism, something quite ridiculous. Virtue is a thing for the daughters of the affluent classes, something ornate and musty, something indecent. The highest values have not only become stale, rather values as such are distasteful, they cannot deny their origin in the spirit of bourgeois commercialism. Idealism is for us not only a thing of the past, it has also proved to be a means of ignoring the individual, the real human being. Responsibility has not only become rare, it also serves, wherever it comes up, as a pretext for evading accountability. What was ethics about, and why has its subject matter become so unclear to us? Ethics as a separate philosophical discipline has existed since Aristotle. It was determined as that part of philosophy that

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relates to action. But what is action? Is somebody who boards a tram to go to the office acting? Is somebody who sits at the desk to draft a physical theory acting? Or is the person who acts someone who builds a house, who bears children, who signs a rental agreement? Acting as an object of ethics was not any human behavior whatever, but was set off from other manners of human existence in three aspects and in various dimensions. As practice it was different from theory, it was a concrete dealing with people and things and not merely knowledge that abstained from intervening in affairs. Furthermore, acting as the living of human life stood in contradistinction to producing, which only had to procure the means of life. And finally, acting as the reality of freedom was the way in which the human being rose above merely succumbing to existence. The Aristotelian distinction between theory and practice was based on the certainty that through reason human beings participate in a divine existence. Since for Aristotle happiness seemed to lie in activity, the opportunity for the highest fulfillment of existence arose in the practice of reason. Such happiness was at the same time independent of concrete circumstances because reason finds its objects in itself or, if need be, can appropriate them by mere contemplation. The bios theoretikos rises above practical life by virtue of its selfsufficiency, its self-reliant independence, which makes the person who lives such an existence unassailable and dispenses him or her from participation in action. As self-sufficient as God, the human being living in theoretical existence was beyond moral distinctions. Whether what was purported to be knowledge was true or false was his or her only question. Knowledge later developed its own schema of perfection according to degrees of clarity and distinctness. The division of good and bad, however, remained foreign to knowledge, which was free of need, because that differentiation, whether with reference to the individual, the community or both, received its meaning from the deficiency of human existence. The moral quality was the human good, that which was beneficial to the human being in its fragile, ephemeral existence.

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No wonder that doubts about the self-sufficiency of theoretical existence set the relationship between theory and practice in motion. In the pursuit of knowledge, practical interests, the desire for dominance, especially over nature, to master the natural distress of existence with such means, became apparent. Where knowledge was not otherwise degraded to a means, its path proved to be an escape route and bore the marks of the practice from which it escaped. The relationship between theory and practice became dialectical, mediated by appropriation, interest and commitment. Just as theory originates from practice, it also takes return effect on practice through the development of interests. This sets new standards for it. Knowledge is not truthful where it does not admit its practical interest. The dialectical suspension of the distinction between theory and practice is the reason for a variety of uncertainties in the moral sphere. It may well be accepted that reflection can be required and that knowledge can be a duty. The negative turn, however, assigning blame due to a lack of these, will meet with resistance. If a technician does not know what commercial interests he or she is serving, if a farmer does not know the side effects of his or her pest control, they will assign responsibility for the practical consequences of their ignorance to others. But at first it seems absurd that knowledge could also be iniquity. The possibilities of nuclear, biological and chemical warfare could be cited as examples, but those scientists who provided the requisite knowledge, even the weapon designers themselves, do not believe that they are responsible for the use of this knowledge. Only acting is regarded as ethically relevant. If knowledge can be iniquity, should even the knowing be avoided? The absurdity with which such a question plays is merely the reflection of a prejudice that orients ethics exclusively to action. The contradictory opposition of commission and omission is reflected in the exclusive alternative of guilt and avoidance of guilt. The dialectics of theory and practice must destroy this alternative. Since in comparison with the archaic conceptions of ethics modern knowledge must in any case be regarded as hybrid, the only possible issue today is, according to these very concepts, how to discharge this guilt.

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Life Now Only Means Production We are beginning to learn that what is supposed to be beneficial for humankind must not be detrimental to the rest of the world of living beings and things. It seems that it is not possible for anything to be good that humankind acquires at the price of the extermination of animal species or the desolation of the countryside. Such experience may well lead to the development of a science which includes in the knowledge of an object knowledge of its goodness.1 Then scientific discipline can only accept as truth something that in terms of conduciveness is adequate to its object. In this sense, the discovery of the insecticidal effect of chlorinated hydrocarbons was not the disclosure of a truth, but the propagation of illusion. The destruction of the environment makes it clear to what extent science, of which we were so proud, contains such illusions. Aristotle distinguished poiesis from practice. This separation of the living of life itself from activities through which its preconditions are created is difficult for us to understand, not only because conceptual pairs in our language—such as “acting and making”—do not grasp the difference, but also because what for us could simply be the living of life constantly turns into production, poiesis. Nevertheless, the difference has been preserved in ethical reflection from Kant’s distinction between moral and technical-practical imperatives up to Habermas’s distinction between interaction and instrumental or goaloriented action. Poiesis is activity that finds its purpose outside of itself. Thus, the activity of building is oriented to the house. However, the house is not an end in itself, but serves another activity, namely dwelling. Something of this kind is what Aristotle calls practice in contradistinction to poiesis. Practice, in this distinction, has its goal in itself. We do not dwell in order to achieve something by this means. If there 1 This idea has been further developed as “social natural science”: Gernot Böhme, Engelbert Schramm (Eds.). (1985). Soziale Naturwissenschaft. Wege zur Erweiterung der Ökologie [Social natural science. Towards an extension of ecology]. Frankfurt/M.: Fischer-Taschenbuch-Verlag.

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is a striving at work in dwelling, it is not oriented to something outside itself, but to the goodness of dwelling itself. For this reason Aristotle asserts: practice itself is its own goal. The distinction between poiesis and practice is the basis for the distinction between techné and phronesis. Techné, understood in the Aristotelian sense, is the knowledge that guides the production of something. This knowledge includes the precise idea of what is to be produced, the knowledge of the necessary material and the possible arrangement of the work procedure. Whoever possesses a techné is in a position to organize the processes involved in poiesis in such a way that what is desired comes out. Whereas the technician is in control in terms of production, he must accept the stipulation of practice as to what is actually to be produced. The producer receives his or her instructions from the user. What must be produced and how it should be made is inferred from what is good in the field of practice, that is, from what constitutes “living well.” Aristotle calls the kind of knowledge that recognizes what human life is good phronesis. It is the ability to deliberate for oneself and with others about it and to come to a conclusion on how one actually wants to live. The exclusive topic of ethics is then practice. Manners of living are morally good or bad according to whether or not what is adequate to the human being comes to fruition in them. Poiesis is neutral in this respect. Whether producing is morally good or bad depends on the use made of what is produced. Accordingly, the knowledge of production, techné, is ambivalent. It does indeed have its own scale of perfection, within techné it is possible to master one’s craft more or less perfectly, but whether techné is morally good or bad depends on the purpose for which it is used. Phronesis, by contrast, is insight into what is morally good. The certainty with which these distinctions were made is astonishing. It is based on the distance from which the free citizen attending to his political being could look down on the craftsman. However, since such distinctions no longer adequately describe our life, at best characterizing it in negative terms, the ethics based on them has lost its force.

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The distinction between practice and poiesis has lost its intelligibility for us, because nowadays almost all living has become poiesis, production. We lie down in the sun to get a tan, swim to stay fit, rest to accumulate energy for the work process. It is expected that something will be achieved in a conversation. A visit to the theatre is expected to be worthwhile. Everywhere we look at the benefits and disregard the performance. The extent to which the advance of technicization has transformed our understanding of existence becomes clear when we consider that large realms of life, which we now take for granted as useful occupations, belonged to the realm of practice for Aristotle. Politics and economics were not, for example, activities intended to achieve certain results, but rather the way in which the public and private life of the citizen took place. Accordingly, the knowledge that was decisive for politics and economics was not a techné, but phronesis, moral insight.

The Inability to Wish If the state nowadays appears to be a huge administrative machinery and an apparatus designed to guarantee general security, if the economy is understood solely as a production process, then the demand to hand both of these over to the standardization officials is justified. They would indeed be able to improve what is happening anyway—of course, only because what is to be done is not subject to question, because the deliberation on how we actually want to live, the deliberation in which, according to Aristotle, phronesis proves its worth, simply does not take place. Ethics is deprived of its field. The categories that qualify our actions as good and bad are those of production: accuracy, punctuality, perfection, efficiency. The concept of the good life itself has yielded to these categories, it has become a vague negative of production. The demand that must be and is being made on our civilization today is not properly termed an ethical one, but rather a pre-ethical one. The question as to what human existence actually means has to be posed. The deliberation of this question would first have to determine the goals to which political and economic behavior should be oriented.

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The primacy of practice over poiesis meant that the living of life determined what production was to produce. Translated into our language, this would mean that the user’s needs would have to be the terms of reference of production. Today, of course, production is still oriented to the market, but that does not mean that it considers the needs of the user, but rather his or her capacity to consume. This transformation is not only to the detriment of a profit-maximizing industry. For where the discussion about the good life falls silent, the development of needs also ceases.2 The person of today is not capable of wishing. Production is thus forced to cope with people’s greatest lack, it is forced to supply them with needs before demand. This reverses the relationship between poiesis and practice. The realm of production determines what is needed and what has to be used in order to live a good life. Before ethical questions can be discussed today, the living of life itself must first be restored to its rightful place, and above all to its primacy above merely productive behavior. In itself, however, this demand is reactionary. For it suppresses that other consequence of the distinction between poiesis and practice, the value-neutrality of what is produced and of the art of producing. Since it was only the use of these things that gave them their ethical relevance, they were neither good nor bad in themselves, a techné as such was neither praiseworthy nor objectionable. A sword could be used against friends and enemies, but outside of such use it was a morally inoffensive tool. This situation has probably been destroyed forever by modern technology. There are objects that no longer admit of use for good or bad so that the very production of them is already ethically relevant. Today, this includes the means of nuclear, biological and chemical warfare, and tomorrow it will include the means of biochemical and electronic manipulation of human beings. However, such possibilities are only an expression of the fact that technology as a whole is becoming ethically relevant. While the production of one thing or another may appear to be equally good given 2

But see as to the transformation of needs into clesire (Böhme, 2017).

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a relatively closed stock of possible products, the continual introduction of new products changes the possibilities of human existence itself. It is then no longer morally indifferent what resources are made available to the human being for life. For example, the production and distribution of pharmaceuticals for non-therapeutic use is not unproblematic because they alter the relationship of the human being to himor herself as a whole. Furthermore, we are also beginning to realize that the production of one product makes the production of another impossible. And finally we have lost the belief that the use of a resource for good makes it good. Antiquity was able to counteract the ambivalence of medical art with the Hippocratic Oath, which bound its use to the well-being of the patient. Today, we are confronted with the ambivalence of medicine in the therapeutic application itself. If the possibilities of medicine used for prophylaxis, diagnosis and therapy can turn out to be detrimental to the patient,3 if the means of pest control themselves cause damage, if the efforts to improve our lives make it more difficult and degrade it, then not only is the use of these resources questionable, but also the knowledge from which they are derived. The distinction between poiesis and practice has thus lost its power to determine the topic of ethics. However, it can serve as a mirror in which we recognize that today we do not know what moral questions actually are. To a certain extent these questions seem to lose their scope completely if it turns out not to be possible to restore the predominant significance of the distinction in the living of life itself. Then there would only be technical questions to solve. To a certain extent, moral questions seem to spread to every area of human activity. Then concepts of good and bad technology would have to be developed; but they could not be determined in terms of technology’s own perfection, nor could they be derived from its application alone. Every ethics is based on the opposition of doing and suffering; indeed, the rigorous elaboration of this opposition was in a certain sense the 3 David M.  Spain. (1967). Iatrogene Krankheiten. Stuttgart: Thieme. [English Original: David Michael Spain. (1963). The Complications of Modern Medical Practice: A Treatise on Iatrogenic Diseases. New York: Grune & Stratton.]

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establishment of ethics itself. People who today read the Iliad without being prepared for it will soon be annoyed when they realize that the heroes to whom they willingly pay respect do not deserve it because it is not they who do their deeds, who make the decisions, but always the gods through them and for them. It was only centuries after Homer, and after in the lyrical age enthrallment was no longer understood as a surge of heroic existence, but as suffering a torn, ephemeral existence, that the human being could achieve a status in which he or she succeeded in acting in his or her own right. This process has been celebrated as the discovery of the mind, as the formation of the soul. From Plato on, who defines the soul as a self-movement, to modern philosophy, which locates the essence of the human being in spontaneity, in freedom, the human being sees his dignity in a principle that enables him to act of his own accord. It is only thanks to this dignity that what happens through man can it be attributed to him; it is only because he can be expected not to succumb to what afflicts him that man becomes the addressee of a moral claim. Thus, the prerequisite of ethics, namely that man is an acting being, itself becomes the content of the claim raised by ethics. Ethics begins with the Socratic question of whether knowledge is predominant. This is the question of a power in the human being that is not subject to the emotions rising from his body and the emotions impinging on him. The preeminent task is to gain this power—in knowledge, reason, will, the intelligible subject. Whether the human being acts good or bad is secondary, even trivial. Since Socrates’s assertion that whoever acts voluntarily, that is, whoever acts at all, does good, up to Kant’s view that only the good will is genuinely will, the belief that there is no malicious action at all lives on, the belief that the adversary who must be combatted can only be sought in the emotions of man, in everything that restricts him in his freedom. The drama of ethics is enacted between knowledge and passion, between will and emotion, between duty and inclination, it is played between the spirit and the flesh.

The World Has Nothing More to Say to Us The impulse of ethics stems from existence as pathos in early history. The human being had to struggle painfully for independence against a

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multitude of dependencies. This could only be achieved by virtue of a rigorous renunciation of everything bodily. The body became a tool, an organ of the acting person, finally in Descartes’s view a machine that is subject to control. If they were accepted at all, the emotions were reinterpreted as acts of the person. The ideal of human existence became the sage who lets his body die off and is no longer affected by any emotion. Today, we can hardly understand the situation to which ethics made reference. Reasonable action seems to us to be a matter of course and easy.4 To the extent that we, too, feel limited in our action, it is social and political conditions that condemn it to ineffectiveness. But the question was not about the effect. We are unaware of the profusion of powerful emotions that can prevent us from doing what we want. The suppression of the body is so thoroughly successful that we only become aware of it when it denies us its service. As a medium of emotional enthrallment, it only receives attention in psychosomatic medicine: pathos has degenerated to the pathological. The world has nothing more to say to us because it no longer concerns us. The atmosphere of a landscape cannot captivate us, a drama cannot make us shudder. There is no despair that tears our hearts apart, longing is for us not an enthrallment, but a striving, love is not a passion, but an act. The civilized person does not cry, and when he laughs, it is only out of courtesy. Coldness is the civilized person’s habit, moderation his nature. All the adages of classical ethics are lost on him. The distinction between doing and suffering has lost its import for the modern human being in view of the predominance of the active way of life. The paucity of emotions, the lack of passions, the paltriness of needs makes it absurd to discipline them today. Whereas classical ethics was an ethics of action, today we would have to demand a reversal, an ethics of receptivity. The banality of ordinary life could make us wish that the human person should learn to let things happen to him again. In a world that understands all forms of being touched 4 On the trivialization of the original goals of a philosophical life see my Einführung in die Philosophie: Weltweisheit – Lebensform – Wissenschaft (2001) [Introduction to philosophy: Worldly wisdom—way of life—science], 4th ed., Frankfurt/M.: Suhrkamp.

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simply as suffering and considers all suffering to be negative, such an ethics would have to develop a new concept of suffering; medical anthropology has taken first steps in this direction. Without renouncing the struggle against suffering, it would have to explain that it is part of human existence. Without abandoning the autonomy of the person, it would have to teach people to yield and to allow themselves to be touched. It would have to be an ethics of pathos. Practice was the topic of ethics. What differed from practice, theory, was above ethics, producing was ambivalent, and ethics repelled the pathic as bad. In the light of such a tradition, under the pressure of the problems of our world, the thing to demand is a kind of knowledge which would not only have to be adequate to its object according to the criterion of correctness, but also that of conduciveness in its context; a techné which would not only become good by virtue of good use; the unfolding of practice and learning of pathos at the same time—these seem to be divergent objectives. Whether this is a mere appearance is neither here nor there. Harmonization is not the preeminent task. Those Greek distinctions, however, arose from a uniform tendency: the emancipation of man from his ephemeral existence. They shaped his self-conception, which remains decisive even in our anthropology. The dichotomy of doing and suffering corresponds to the dualism of body and mind. The body, subject to all influences, servant and instrument of the soul, is merely passive. Its opposite is the self-moving soul as the active principle. Such interrelationships may indicate that ethics can only be unified to a whole again when humanity reaches a new conception of itself.

References David Michael Spain. (1963). The Complications of Modern Medical Practice: A Treatise on Iatrogenic Diseases. New York: Grune & Stratton. Bøhme, G. (2001). Einführung in die Philosophie: Weltweisheit – Lebensform – Wissenschaft [Introduction to philosophy: Worldly wisdom – way of life – science], 4th ed., Frankfurt/M.: Suhrkamp.

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Böhme, G, Schramm, E (Eds.). (1985). Soziale Naturwissenschaft. Wege zur Erweiterung der Ökologie [Social natural science. Towards an extension of ecology]. Frankfurt/M.: Fischer-Taschenbuch-Verlag. Bôhme, G. (2016). Gut Mensch sein. Anthropologie als Proto-Ethik. Zug: Die Graue Edition. Böhme, G. (2017). Critique of Aesthetic Capitalism. Milano: Mimesis International.

Care of the Self and Care of the Other Bernhard Waldenfels

In an ancient Latin legend that Martin Heidegger unearthed and interpreted philosophically, Cura, the personification of care or concern, appears as a hybrid being consisting of heavenly spirit and earthly body. To this day care haunts the world in manifold forms. The basic figure is concern [Sichsorgen], which in the form of taking care or providing [Besorgen] cares for something or in the form of care of oneself or solicitous care of others cares for someone. In the background is fearful care or worry [Besorgnis] as an emotional state, a feeling. Thus, care is integrated into our dealing with things, others and ourselves by distributing the focuses of our vitality. Carelessness is itself a mode of care just as keeping silence is a mode of speech and, more recently, disposal [Entsorgen] is a kind of providing [Besorgen]. General concern applies to those everyday worries that in the Sermon on the Mount are committed to divine care: “Therefore I tell you, do not worry about your life, what you will eat or drink; or about your body, what you will wear.…” (Matthew 6: 25). Our concern in the following discussion shall be not so much this deeper concern, but rather care as a basic feature of the practice of life. It appears in everyday form, for example in the form of carefulness and in institutional form as care for children and old people, as preventive medicine, as public welfare, as custody of children, as religious or secular pastoral care. The question then arises as to what lies behind this care, where and how it is anchored in life, how care shapes people. In the following discussion we shall pursue the relationship between

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care for self and care for others and place special emphasis on medical care, expressed verbally in “cure.” On the train of thought: the first two sections are meant to provide orientation; they shall briefly illuminate the philosophical background of care for the human being and the changes it has undergone from antiquity to the modern era. The third part focuses especially on medical care, particularly in the form of responsive therapy, which represents a radicalization of care for others.1

1. Collective Care of Self Let me begin with Plato. He is the first Western philosopher in whose work care appears as a central motif. Care in the Greek sense of epimeleia is derived from the verb melein: it is a care to me, it concerns me. We encounter it in a pointed sense in Socrates’s defense (Apologie 29 d–30 b). There, Socrates avows that he has admonished all not to care for possessions, for physical goods, money, fame and honor before they have cared for themselves, for their souls. Psyche is not to be understood dualistically here, as the counterpart to soma, but rather as the principle of life, as “that whereby we live” (Republic IV, 445 a). Furthermore, Socrates admonishes that one should not concern oneself with the affairs of the polis, with political questions, before concerning oneself with the polis itself. In differentiating care the following points must be kept in mind. (1) The self of care does not pertain to life pure and simple (zˉen), but rather the good life (eu zˉen); the aim of care is that the self shall become as good as possible. (2) Care of self is an extended care of self in which everyone at the same time cares for the others; for the good with which each is concerned is a common good, a good for us all The present text stems from a lecture at the 21st annual conference of the Viktor von Weizsäcker Association in Freiburg, Germany, October 9–11, 2015, available in German at the webpage of the association: https://viktor-von-weizsaecker-gesellschaft.de/texte/vortrag2015_Bernhard_Waldenfels.php?id=13&sID=9 Meanwhile an extended version (in German) appeared as the final chapter of my book: B. Waldenfels (2019), Erfahrung, die zur Sprache drängt. Studien zur Psychoterapie aus phänomenologischer Sicht, Berlin: Suhrkamp. 1

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that constitutes the foundation for living together (syzēn) of friends and citizens. (3) Human care has a cosmo-theological background. God cares for the world, for nature as a whole as well as for the smallest things in it (Laws X, 899 d–905 d). (4) Care characterizes certain professions such as that of the politician, identified as the “art of care” (Statesman 276 d), and that of the caregiver, who takes care of the body either as a gymnastics trainer or a physician (Gorgias 464 b). Thus, the ethos of care is based in a natural kinship of human beings. This continues in late antiquity as a link between care of self and care of others, implemented in social practices and integrated into an art of living by authors such as Epicure, Seneca, Zeno and Epictetus, but in a largely depoliticized form. Michel Foucault treats this ethics of care from late antiquity in detail in the third volume of his history of sexuality under the title Souci de soi—The Care of the Self. In Chapter II, epimeleia is discussed in detail, starting with Socrates as the “master of the care of the self” (Foucault, 1988, p. 44). However, care is integrated into an “aesthetics of existence” and a “culture of the self,” thus acquiring a modern hue that raises questions about its binding social character. As far as the scope of collective care of the self in the ancient world and order of life is concerned, clear limits can be seen. In the strict sense, there can be no talk of care of the other. Care is inclusive, related to a We, not to a solitary I, but membership in the We is limited considering slaves, barbarians, the dishonorable, the irrational and the godless, not to mention the disabled. Aristotle’s Politica (VII, 16) envisages a law forbidding the upbringing of a crippled child, and conversely prompt abortion is prescribed when a stipulated number of children is exceeded. Good life takes on the form of eugenics that runs utterly counter to the Hippocratic Oath, which dates back to the fifth century before Christ. What was practiced in the Third Reich as the “extermination of worthless life” also has its pre-history.

2. Conflict between Care of Self and Care of Others The common ground anchored in a natural and divine order breaks apart when in the modern era the physis as a comprehensive teleological

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order yields to a nature that is limited to pure cause–effect relationships and a play of forces. Mother nature becomes the provider of “almost worthless materials,” as John Locke dispassionately states in his Second Treatise of Government (V, 43). From mater to materia, we could summarize, and add for the present era the matrix. In his Pensées, Blaise Pascal registers the shock that befalls a person who up to now had been used to a sheltering nature. I feel engulfed by the vastness of spaces “of which I am ignorant, and which know me not.” “The eternal silence of these infinite spaces frightens me” (edition of Lafuma Frg. 68, 201, 1963). There is nothing that responds to my questions, that takes care of me. As a consequence of this breakdown, care becomes a problematical notion. I shall illustrate this with reference to four thinkers. The first thinker is Thomas Hobbes, who unsettled practical philosophy as radically as Descartes theoretical philosophy. The fundamental anthropological dogma is: “The prime good for every man is self-preservation (conservatio sui)” (De homine 11, 6). This centering on self-interest and the own needs of the first person takes place against the background of a fundamental peril that became glaringly manifest in the religious civil wars of the seventeenth century. The “chiefest of naturall evils,” the evil that fills us with fear, is violent death at the hand of another; the necessity with which each person flees from this evil is no less than the necessity with which a stone falls to earth (De cive I, 7). As a potential deadly enemy, man is a wolf to man: homo homini lupus. The only way out of this natural bane is the artificial social contract, which converts individual egoism into a collective egoism. This does not change anything about the basic drive of the human being. Care is not a primary motive. The Jewish thinker Baruch de Spinoza continues with the primacy of self-preservation in an ontological striving for being (conatus essendi): “Each thing, in so far as it is in itself, endeavours to persevere in its being,” he says in one of the propositions of his Ethics (III, 6). This perseveratio, which amounts to a kind of moral law of inertia, is clearly distinct from the Greek form of sōtēria (= deliverance, preservation), which is related to sōs (= whole, intact, preserved) and bridges the gap to “healing.” In Spinoza, the egology derived from inertia is theologically elevated

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in an all-pervasive love with which God loves himself in everything (V, 36); but here, too, self-love sets the tone. Since the early modern era, egoism and altruism have been involved in a quarrel that does not come to an end because thesis and antithesis condition each other. It takes on totalitarian features when egoism is extended to an ethnic collectivism, which in the form of “political medicine” did not even spare medicine. It is no better with the collectivism of social classes. The care for the other diminishes with the alienness and difference of the other. Let me now present two other thinkers who attempt in opposite ways to give new life to the motif of care. Let us begin with Martin Heidegger, who left a deep mark on the genius loci of Freiburg. In his work Being and Time, first published in 1927 in German, Care plays a decisive role (§§ 26, 41f.). It receives an existential–ontological determination (cf. pp.  191–193, English 235–238). “Dasein is an entity for which, in its Being, that Being is an issue [es geht um …].” The expression “es geht um …” or “is an issue” corresponds to melein, the core of the Greek epimeleia. What then is the status of the relationship between care of the self and care of the other? “Being an issue …” is determined as “Dasein’s ‘Beingahead of itself.’” Temporality, granted, but also alterity? The author explicitly declares the expression “care for oneself” [Selbstsorge] to be a tautology inasmuch as the self is structurally contained in care as a caring attitude towards the self (p.  193, English 237). The same applies to concern [Besorgen] for something and solicitude [Fürsorge]. In the latter case a distinction is made between Being-with [Mitsein] as a structural “determination of Dasein which is in each case one’s own” and the factual Dasein-with [Mitdasein] of others. In his book The Other (1977), Michael Theunissen comments as follows: The originality of Being-with obscures … the originality of Dasein-with. For whereas the former consists in the fact that Being-with belongs to the structure of Dasein, the latter means that the other’s Dasein-with is not a structure of my Dasein. (p. 169)

The decisive point is that Dasein remains bound in the circle of selfbeing and that others are merely inferred from one’s own being. Care

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for others or solicitude [Fürsorge] moves between the two extremes of a surrogating care that “leaps in” for the other, which relieves the other of their care, and a care that “leaps ahead” of the other, which returns their care to them (p. 122, English 158–159). What is missing is the intermediate form of a helping, attentive care; it is already encountered in the Socratic maieutic method, and is familiar to us in everyday and institutional forms. The separation of the “ontic” from the “ontological,” the separation of the “sorrow for things that exist” from “safeguarding and conservation of the truth of being”2 has the consequence that care as a “factual social arrangement” is reduced to the deficient mode of an “everyday, average Being-with-one-another” (p. 121, English 158). Basic elements of society such as money and weapons and basic social hardships such as hunger and illness are not included in the analysis of being-with at all. Emmanuel Levinas already criticized this point. A thinker of Jewish–Lithuanian origin who emigrated to Paris in good time, he was in Freiburg as a guest of Husserl’s and Heidegger’s, and later distanced himself clearly from Heidegger, not only for political reasons. In chapter IV of his work Otherwise than Being or Beyond Essence (French 1978, German 1992, English 1981), he develops a radical form of originary substitution by conceiving the self on the basis of the alterity of the other.3 In so doing, he confronts us with the question: “Why does the other concern me”—“Pourquoi Autrui me concerne?” and with the question from Hamlet: “What is Hecuba to me?” and with the question from the Bible: “Am I my brother’s keeper?” His answer does not consist of arguments, which would always come too late, rather his answer is: “These questions have meaning only if one has already supposed that the ego is concerned only with itself, is only a concern for itself [souci de soi]” (1992, p.  260, French 150, English 117). This presupposition is vitiated 2 Cf. Die Metaphysik des deutschen Idealismus [The metaphysics of German idealism], lecture held in 1941 (GA 49, p.  55). More text references can be found in Helmuth Vetter, Grundriss Heidegger (2014), p. 89f., 242f. 3 Cf. on this point my discussion in: Hyperphänomene (2012), chapter 8: “An Stelle von...” [Instead of …]

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when the other’s demand is prior to my initiative and thwarts my needs, and does so inevitably; and this means that my own word [Wort] is an answer [Antwort] , that is, that it comes from elsewhere.

3. Therapy between Pathos and Response I shall address and indirectly answer the question of the import of care of the other by turning my attention to medical therapy as a form of responsive therapy. I do not regard therapy as an application of care, but rather as a specific embodiment of care that does not presuppose a pure consciousness nor a pure existence [Dasein], but rather a corporal self that by virtue of its corporality is situated in the world and by virtue of its intercorporality is related to others in manifold ways.4 I refer especially to Kurt Goldstein, the Jewish–German neurologist, who was seven years older than Viktor von Weizsäcker and in the period between the Wars was, with the psychologist Adhémar Gelb, the co-director of a hospital in Frankfurt devoted above all to the diagnosis and treatment of disabled war veterans. The proximity to Viktor von Weizsäcker’s concept of a medical anthropology is unmistakable, but there are also important differences that must not be overlooked. It was not until 1934, after the author had been exiled from Germany, that Goldstein’s fundamental work, The Organism, subtitled “a holistic approach to biology derived from pathological data in man,” was published in German in The Hague at the publishing house Martinus Nijhoff.5 This author played an important part

As a representative of many discussions on the part of philosophy, cf. my lecture course Das leibliche Selbst [The corporal self] (2000), and on the part of medical anthropology Thomas Fuchs: Leib und Lebenswelt [Living body and life-world] (2008). 5 This important book, which has long been available in French translation (in a series edited by Merleau-Ponty and Sartre) and in English translation (in the most recent edition with a foreword by Oliver Sacks), was first published in Germany by the publisher Fink in 2014 with introductory commentaries by the editors. An earlier work by the same author with an explicit reference to our topic is also worthy of mention: Die Behandlung, Fürsorge und Begutachtung der Hirnverletzten [The treatment, care and assessment of patients with brain injuries] (1919), Leipzig. 4

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for me in the development of the responsive phenomenology on which the following outline of a responsive therapy is based.6 3.1. Illness as Lack of Responsivity Like numerous other researchers of his period, among them Jakob von Uexküll, the Berlin Gestalt theorists, Erwin Straus and Viktor von Weizsäcker, Goldstein does not take a duality of subject and object, of inner mental world and external physical world as his point of departure, but a grappling of the organism with its environment. Grappling means exchange, but also instability, disruption, impairment, agitation. In this context, Goldstein defines health as responsivity, that is, the ability more or less to cope with the exigencies of the environment, and disease accordingly as irresponsivity. Healing would then ultimately consist in enhancing or restoring responsivity. Goldstein makes reference to the Virchow school in this context, in particular to the Grundlagen ärztlicher Betrachtung [Fundamentals of medical observation] (1921) by Louis R. R. Grote. This means that he attributes considerable importance to the social conditions of illness. The studies that he and his staff conducted on the patient Schneider over many years became famous. Schneider was a war invalid who suffered from an injury to the optical brain regions caused by fragment munition with specific effects on all fields of behavior such as perception, speech, counting, pointing, fictive and sexual behaviour.7 The following discussion shall focus solely on basic aspects of responsivity encountered in therapy. When in the following discussion physician and therapist are mentioned, this is to be More on this topic can be found in a broader context in my Antwortregister [Responsive register] (1994), pp. 457–461, and in the book Grenzen der Normalisierung [Limits of normalization] (1998, new, extended edition 2008), chap. 5: “Response und Responsivität in der Psychologie” [Response and responsivity in psychology] and above all chap. 6: “Der Kranke als Fremder. Therapie zwischen Normalität und Responsivität” [The patient as an alien. Therapy between normality and responsivity]. 7 Research on the link between brain injury and behavioral disorders received global attention from philosophers such as Max Scheler, Ernst Cassirer, Aron Gurwitsch and Maurice Merleau-Ponty, from art theorists such as Rudolf Arnheim and from physicians such as Georges Canguilhem, Alexander Lurija and Oliver Sacks. 6

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tacitly understood as partes pro toto standing for all who participate in the treatment of and care for the ill. The community of care would be a topic in its own right. 3.2. The Primal Scene of Medical Treatment Much as Viktor von Weizsäcker does it at the beginning of his essay Die Schmerzen [Pain], I use a Freudian expression, primal scene, to refer to the starting point of treatment. A primal scene can only be conceived as a pre-supposition, as an implicit prerequisite for medical action. It corresponds to what the late Husserl describes in his work the Crisis (Hua VI, p. 73, English p. 72, and Appendix III) as a primal establishment [Urstiftung]. It is only in retrospective reflection that such an establishment or foundation, such as the origin of geometry or the birth of the tragedy, turns out to be such a foundation. The primal medical scene with which we are here concerned is that the patient, literally the sufferer, comes to the physician or is brought to the physician. “The sick person, the person in need, who needs help and therefor calls the physician” is a “primal phenomenon,” that is, a phenomenon that cannot be deduced from others (“Der Arzt und der Kranke” [The physician and the sick person], GS 5, p. 13). There is no separate cause or, as the German puts it, no separate “primal thing” [Ur-sache] behind the pathos (cf. Gestalkreis, GS 4, p.  314). The pathos coincides with its effect. It is expressed in the form of primal appeal such as “I am ill” or “I am in pain.” But this “I” already says too much; it would be more precise to say: “It hurts me” or “It is painful.” This is not a process that can be described in the third person, but also not an act that can be described in the first person.8 8 In his early essay “Der Arzt und der Kranke” [The Physician and the Sick Person] in which the echo of Buber’s book I and Thou can be heard, Viktor von Weizsäcker leaps from the utterance “I am ill” directly to the assertion “something is ill,” such as the lung; here the I is abstracted from the Ego and replaced by the Id (GS 5, pp. 23f.). In the essay “Die Schmerzen” [Pain], a similar distinction is made between “I-state” and “it-state,” between ego and environment, but in such a way that a “dynamic state of abeyance” is ascribed to pain as an “affection of the I by the id”: Pain is correctly conceived when it is conceived “as a pending decision between

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As  a  patient I am involved in pain from the beginning, but not in the nominative of the originator or agent force, but in the accusative or dative of the patient or sufferer. The initial question is not who does something, but rather to whom something occurs or who is touched and affected by something. The beginning is “not made by me, rather it comes when the patient comes” (“Der Arzt und der Kranke,” GS 5, p. 26). Pathos receives its primary expression in the “lament” (p. 25), expressed in body language or verbal language, the cry for help, not in an assertion or an accusation. Accordingly, everything the physician says and does, starting with the question he asks, emerges from a primal response that addresses pain. This description of the enactment of medical work is about what makes the patient a patient and the physician a physician, not about what someone might be thinking in this work. If the relationship between the sick person and the physician is asymmetrical, involving appeal and response, we are not moving in a closed circle, within which meaning emerges from meaning as in the hermeneutic circle of mutual understanding. Nor are we moving in a “life circle” as a return to ourselves, a “self-encounter in the eternal return to the origin,” which has the last stammering word in the Gestaltkreis. Like Hegel’s odyssey of mind, this odyssey of life founders on the cliffs of alienness. If we wish to adhere to the geometric analogy, we should rather think of an ellipse with two focal ego and id” (GS 5, p. 32f.). In the Gestaltkreis [The Gestalt circle] (GS 4, pp. 307f.) we continue to encounter an “opposition of ego and id” and in addition a “shiftability of the ego-id-limit in the realm of our own corporality.” Tinkering with the old transcendental and speculative building blocks subject and object, ego and nonego leads us towards a phenomenology of bodily ambiguity, close to what Maurice Merleau-Ponty developed in incipient form in La structure du comportement (The Structure of Behavior, first published in French in 1942) and full-fledged in the Phénoménologie de la perception (Phenomenology of Perception, 1945), but it only takes us into the area. Drawing on Buber and also on Weizsäcker, in the Zwischenreich des Dialogs [Intermediate realm of dialogue] (1971, pp. 249-255) I determined the therapeutic dialogue in analogy to the pedagogical dialogue as an indirect dialogue that addresses the other, but in a specific perspective, placing itself between Thou and it, between the addressee and the objective reference.

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points: pathos and response, undergoing an intrusion and replying. Like any response that is given anew and not simply replayed, the response begins elsewhere, in the gravitational field of an other who escapes our grasp. In our case, it starts with the patient as an other to whom an answer is given or from whom it is withheld. In his book Eclipse of God, Martin Buber points out that the commandment of love in Leviticus 19: 18 and 34 contains a unique dative construction which could literally be reproduced as “I shall love to him” (1962, p.  545). Thomas Aquinas speaks similarly: “Amor est alicui velle bonum” [Love is wishing good to another] (Summa theologiae I/II, 26, 4). In a similar context, I have spoken of a dialogical dimension of action (Antwortregister [Responsive Register], pp.  452–456). With this in mind, let us now look into the status of care. If in general care means that someone is concerned about someone, the physician as a physician is specifically concerned about the well-being of the patient. Care for the other is thus inherent to the care practiced by the physician, but it is a care that cannot be traced back to self-care. This does not mean that physicians are morally superhuman, but it does mean that they are subject to a professional requirement, whether they want it or not. This requirement is also the basis of the ancient Hippocratic Oath, which expresses what the physician has to do when he acts as a physician. Socrates thinks this way, too, when he assesses all activity with reference to its intended outcome. In this sense, the phrase Der gute Arzt [The good physician], which Klaus Dörner used as the title of his monograph (2001), refers to the physician as such and not to a moral supplement. 3.3. Time Shift in Therapy As we have seen, Heidegger determines care as one’s own Dasein’s Being-ahead of itself. The double process of pathos and response, by contrast, suggests a Being-ahead of oneself with the Other, an amalgamation of temporality and alterity. The appeal of the other is prior to my initiative, the response is unavoidably deferred. It is delayed because it does not begin with itself, but rather crosses a “threshold of otherness” (cf. Sozialität und Alterität [Sociality and alterity],

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chap. 7). In this context, I speak of an originary time lag, a diastasis. I am who I was and who I shall be, but this antecedence and deferral is not rounded out in a self-referential whole as in the Hegelian dialectic, in which mind returns to itself and sublates its beginning. In the treatment of traumatic events, for example the treatment of the wolf man, Freud speaks of an indispensible deferral which manifests itself in the aftermath of the injury and imposes on the treatment the character of an after-treatment. Our own birth is an “original past, a past which has never been a present” (Merleau-Ponty, 1966, p. 283, French 280, English 242), the command of the other’s face comes from an “immemorial past, which was never present, began in no freedom” (Levinas, 1992, p. 198f., English 88); the point is not that something was earlier, but that something comes too early to be fully appropriated and understood. Pathos and appeal point to a prebeginning that cannot be annulled. For this very reason there is no definitive answer, neither in life nor in therapy. 3.4. Transformation of Suffering into a Case of Illness Viktor von Weizsäcker is certainly right to emphasize the character of our experience as pathos which is not at our disposal. But is it possible to simply contrast the pathic with the ontic? Is the pathic state synonymous with the annulment of the ontic state, as he writes in Gestaltkreis (GS 4, p. 314)? In his 1936 book Vom Sinn der Sinne [On the sense of the senses], Erwin Straus envisaged a polarity of the gnostic and pathic and “transitions from orienting-on to being-struckby” (1956, p. 394). An opposition between logos and pathos would in fact contradict any patho-logy that gives words to pathos as pathos.9 Such a thing as pathology seems impossible without the transformation of singular suffering into something that is understood, explained and treated as something, as a heart attack, gallstone, allergy, paralysis, anxiety neurosis or persecution mania. In this way, 9 On this point, cf. my Bruchlinien der Erfahrung [Fault lines of experience] (2002), Part I: “Bedeuten und Begehren auf pathischem Hintergrund” [Meaning and desire against the background of pathos].

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the ill person’s singular suffering turns into a general case of an illness, similar to judicial proceedings, in which the act of violence, which injured someone in the flesh, is judged to be a case of bodily harm or attempted murder. The own body, which, as a physical body, has features of the body of an other, functions as a “point of conversion” [Umschlagstelle], as Husserl puts it (Hua IV, p. 286, Ideas II, 299), at which these transformation processes take place. The disturbanceprone and pathogenic alienness of one’s own body becomes evident in something like fatigue, which separates me from myself. With critical reference to Merleau-Ponty’s treatment of the “body as a phenomenon” and the corresponding transformation of corporality into physicality, the Heidelberg internist Herbert Plügge speaks of an “experience of materiality” (Der Mensch und sein Leib [Man and his body], 1967, p. 41).10 Freudian slips such as stumbling, stuttering and missing the word are also processes of the physical body in which speech and movement escape one’s control. Adapting a well-known phrase of Helmuth Plessner’s, we can say: I am my suffering and have a disease. In the gap that opens up in and on the own body, medicine finds its place as a science and techno-science with all its diagnoses, medications, operations and equipment. A phenomenology of the body, which reckons with the possibility of dissociation and alienation of one’s own body, has no reason for antitechnical sentiments. However, the temporality of the history of the affliction together with the requisite pre- and post-treatment, precautionary examination and aftercare seems to me to be quite important. This includes the factor of pathos at the beginning and at the end. Just as it hurts at the beginning, at the end it heals, if everything goes well. This is given verbal expression in the fact that verbs such as heilen, guérir and heal are used in both the transitive and intransitive. Salutary medicalization, however, turns into medicalism when healing is seen simply as a process 10 The author also speaks of the role of caring in situations in which the own body is alienated from the person, such as in disease and old age, referring to his own article “Arzt im Irrsal der Zeit” [Physician in the madness of time] in the 1956 Festschrift for Viktor von Weizsäcker (p. 39).

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of making healthy and detaches itself from its origins in pathos and response. We must also warn against the remedies presented in spiritual jargon praising “spirituality as a resource” to be administered by people with “ritual competence.” The analytical philosopher Wolfgang Stegmüller once called this semantic pollution. 3.5. Restoration of Responsivity Responsive therapy means an intervention that takes care not to relieve the other of giving his own response, but also not to give free rein to the other’s response. Between faire, that is, simply doing something, and laissez-faire there is a therapeutic intervention that neither begins with itself nor ends with itself. Each response has an a quo and an ad quod, a from-which and a to-which. Kurt Goldstein, of whom we have already spoken, understands therapy as a “helping action”11*1 corresponding to the endangered and vulnerable existence of the human being. In the case of pathological non-responsivity, this means accepting the fact that the environment contact is limited, but it also means making the demands so high that real responsiveness can be elicited (2014, p. 343f., English 446f.). In conclusion, let me present a healing attempt that explicitly pursues this direction. It can be found in Oliver Sacks’s famous book The Man Who Mistook His Wife for a Hat (1985). The chapter has the simple title “Hands”. Viktor von Weizsäcker regards the pain-relieving touch, which a child is already capable of, as “the first healing action” (“Die Schmerzen,” GS 5, p.  28). In Oliver Sacks’s account there is a spastic woman who has suffered from cerebral palsy from birth. She was unable to use her physiologically intact hands and was dependent on help from other people throughout her life. “She had behaved, for sixty years, as if she were a being without hands.” Sacks suggests moving the food items on the table a little out of reach to elicit a hand movement of her own from the patient. The experiment works like a miracle. The author comments: “‘In the beginning is the [Translator’s note: In the passage in question, the English translation has “medical treatment.”] 11 *1

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impulse.’ Not a deed, not a reflex, but an ‘impulse’, which is both more obvious and more mysterious than either ….” (p.  91, English 68). The impulse is mysterious because it does not belong to the usual repertoire of behavior. It comes from elsewhere, not only for the patient who follows the impulse, but also for the therapist who clears the way for her. A therapy of this kind is what I call responsive therapy: a therapy that responds by getting the other to respond. Care of the self and care of the other merge here. Responsive therapy fits into a responsive ethic, which steadfastly takes not its own projects, but the demands of others as its point of departure. The maxim is not something alien in contrast to what is one’s own, but something alien within one’s own, and thus also care of the other within care of the self.

References Buber, M. (1962). Gottesfinsternis. Werke (Vol. I). München: Kösel Verlag. Dörner, K. (2001). Der gute Arzt. Stuttgart: Schattauer. Foucault, M. (1986). Die Sorge um sich (U. Raulff & W. Seitter, Trans.). Frankfutt/M.: Suhrkamp. [(1988). The History of Sexuality: The care of the self. New York: Knopf Doubleday.] Fuchs, T. (2008). Leib und Lebenswelt. Neue philosophisch-psychiatrische Essays. Kusterdingen: Graue Edition Goldstein, K. (2014). Der Aufbau des Organismus: Einführung in die Biologie unter besonderer Berücksichtigung der Erfahrungen am kranken Menschen. Paderborn: Wilhelm Fink. Grote, L. R. R. (1921). Grundlagen ärztlicher Betrachtung, Berlin: Springer. Heidegger, M. (1953). Sein und Zeit (7th ed.). Tübingen: Max Niemeyer Verlag. Heidegger, M. (1991). Die Metaphysik des deutschen Idealismus. Gesamtausgabe II/49. Frankfurt/M: Klostermann. Husserl, E. (1952). Ideen zu einer reinen Phänomenologie und phänomenologischen Philosophie (Hua IV). Den Haag: Nijhoff. Husserl, E. (1954). Die Krisis der europäischen Wissenschaften und die transzendentale Phänomenologie (Hua VI). Den Haag: Nijhoff. Lafuma, L. (1963). Pascal edition, i. e.  Pensées  (in OEuvres complètes), edited by L. Lafuma. Paris: Gallimard. Levinas, E. (1952). Jenseits des Seins oder anders als Sein geschieht (T. Wiemer, Trans.). Freiburg, München: Alber. [(1974/1981). Otherwise than being or beyond essence (A. Lingis, Trans.). Pittsburgh: Duquesne University Press.] Merleau-Ponty, M. (1966). Phänomenologie der Wahrnehmung (R.  Boehm, Trans.). Berlin: De Gruyter.[(2013). Phenomenology of Perception. London, New York: Taylor and Francis.]

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Plügge, H. (1967). Der Mensch und sein Leib. Tübingen: Niemeyer. Sacks, O. (1990). Der Mann, der seine Frau mit einem Hut verwechselte (D. van Gunsteren, Trans.). Reinbek: Rowohlt Verlag. [(2015). The man who mistook his wife for a hat. London: Pan MacMillan.] Straus, E. (1936). Vom Sinn der Sinne. Berlin 21956, Reprint mit Vorwort von Paul Christian 1978. Theunissen, M. (219772). Der Andere. Studien zur Sozialontologie der Gegenwart. Berlin: De Gruyter. Waldenfels, B. (2019). Erfahrung, die zur Sprache drängt. Studien zur Psychoterapie aus phänomenologischer Sicht. Berlin: Suhrkamp. Waldenfels, B. (1971). Das Zwischenreich des Dialogs. Sozialphilosophische Untersuchungen in Anschluß an Edmund Husserl. Den Haag: Martinus Nijhoff. Waldenfels, B. (1994/2007). Antwortregister. Frankfurt/M.: Suhrkamp/ Taschenbuchausgabe. Waldenfels, B., & Giuliani, R. (Ed.). (2000). Das leibliche Selbst. Frankfurt/M.: Suhrkamp. Waldenfels, B. (2002). Bruchlinien der Erfahrung. Phänomenologie Psychoanalyse Phänomenotechnik. Frankfurt/M.: Suhrkamp. Waldenfels, B. (1998). Grenzen der Normalisierung. Studien zur Phänomenologie des Fremden (Vol. 2). Frankfurt/M.: Suhrkamp. (2nd extended edition published 2008) Waldenfels, B. (2012). Hyperphänomene. Modi hyperbolischer Erfahrung. Berlin: Suhrkamp. Waldenfels, B. (2015). Sozialität und Alterität. Modi sozialer Erfahrung. Berlin: Suhrkamp. Vetter, H. (2014). Grundriss Heidegger. Ein Handbuch zu Leben und Werk. Hamburg: Felix Meiner. Weizsäcker, V. v. (1987). Der Arzt und der Kranke. Gesammelte Schriften 5. Frankfurt/M.: Suhrkamp. Weizsäcker, V. v. (1987). Die Schmerzen. Gesammelte Schriften 5. Frankfurt/M.: Suhrkamp Weizsäcker, V. v. (1997). Der Gestaltkreis. Gesammelte Schriften 4. Frankfurt/M.: Suhrkamp.

Care as Encounter in Situations Hermann Schmitz

In nursing science, authors such as Heidegger, Levinas and Martin Buber enjoy prestige because they are concerned especially with the I-Thou relationship, with our fellow human beings, and have drawn attention to the importance of appropriate behavior towards our fellow people. This is indeed enormously important in order to generate the right attitude, that is, a relationship to fellow human beings that is suitable for bearing serious responsibility, but it is not sufficient because it is possible to be a conscientious person and at the same time very tactless, transgressing many very subtle boundaries that have to be respected in dealing with people in need of care. Therefore, it is necessary to embed this I-Thou relation into situations. Authors such as Heidegger, Levinas and Martin Buber are singularists, that is, they tend to constitute what is given from singular entities. I have studied the types of multiplicity in great detail; the uppermost is the type of the singularity or of the numerical multiplicity, the multiplicity of what can be an element of a set with a quantity; I have isolated this type, but demonstrated that it is dependent on deeper types of multiplicity, especially the type of situations. A situation, then, is a multiplicity that is kept together holistically, that is, it is more or less delimited from outside and coherent in itself by virtue of an internally diffuse significance made up of states of affairs, programs and problems. The significance is internally diffuse because not everything within it is singular. A singular is something that increases a quantity by one. I have provided various definitions of the

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singular, but now I shall make do with this particularly suggestive one. This is a situation in a very general sense; the whole world is pervaded by situations. We live in situations with such internally diffuse significance. These situations are sometimes of more or less long duration so that they only change gradually. I then speak of static situations; but sometimes situations can vary from moment to moment so that it makes sense to examine them constantly with respect to changes; then I speak of current situations. Static situations are, for example, the language that someone speaks or the personality of a person, the general living conditions in a collectivity, say a family or a group, a city, an ethnic group and the like, and also all the competencies that a person has as resources, for example knowledge or dexterity. The exercise of such dispositions are then current situations. This concept of situation is exceptionally comprehensive. We human beings constantly live in situations and on the basis of situations. For the most part they are inconspicuous and do not become countable, but there are also conspicuous situations that stand out for themselves such as an encounter with a remarkable person or a remarkable landscape and the like. All of this is encompassed by the very broad concept of situation. To every situation there belongs a significance consisting of meanings which is not numerically countable, but rather internally diffuse. By meanings I understand either states of affairs, for example that something exists, programs, that is, that something should be or is desired to be, and problems, that is, whether something is or should be or is desired to be. That is the general concept of situation and the subdivision in static and current situations. Let me now elaborate on this. The person becomes familiar with situations by grasping in bodily communication of the type embodiment their internally diffuse significance consisting of states of affairs, programs and problems. He isolates singulars from the contents of these situations; in this process, language is of indispensable service. By virtue of language, he can isolate the singular and thus a countable manifold that is an element of a set that has a number (there is no need to state the exact definitions of the singular here); this has the great advantage that the person learns to

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deal with genera. Something is singular only as a case of a genus and thus an element of a set, which is the extension of the genus and has a quantity. The genera define what a set is and what an element is, specifically, a case of a genus; all the cases together constitute the set, and the genera together constitute a system; they can be grouped to form systems, configurations of single genera, and the content of situations can be transported into this system of genera; what was not singular in the situations and is thus not completely differentiated takes on a thoroughly differentiated and countable form in networks of genera that for their part constitute sets together with all other configurations that only receive numbers by virtue of sets. This ability of the person enables him to withdraw from situations so that he is alone facing what surrounds him, whereas in the earlier state of animals and small children the situations give him the instructions as to how he is to direct or avert his vital drive. But this instruction by the situation, this instinctive behavior of obedience to the nomos of the situations is no longer decisive for the human person. He has to orient himself in the world and does this in many ways, by transforming it, for example by homogenizing space and time or by reification of what at first presented itself as a semi-thing, and the like; in this way, the person develops a very definite view of the world in which he can orient himself more or less. This potential of the person to orient himself in the world is based on the construction of singulars, both single genera and single sets, inasmuch as what is absolutely identical only becomes singular by being at the same time a case of a genus as this singular, not only together with others. This, then, is the person’s opportunity to orient himself in the world. It is at the same time a temptation: the person now has the possibility of arranging the world for himself in a system of singulars, single genera in which everything is accommodated as a single case of a genus; in acquiring this ability, the person may too easily succumb to the temptation to forget and ignore the basic situations in favor of the constructs and to abide by constructing alone. This, however, is dangerous because in so doing he is sawing on the branch that he is sitting on; the person only achieves such a system of constructs by in fact drawing on situations, for example by virtue of language, and then by connecting and assembling what he

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has derived from the situations as basic ideas. But he cannot make do without drawing from situations. Therefore, after the person has withdrawn from situations it is indeed important for him to have the ability to transform situations into constructions, constructs and configurations of singulars in order to survey the situations, take them in hand and adjust them in planning. But it is exceptionally important for him not to forget the situations; this applies especially to the treatment of people who are suffering; all ill people are among them, and also those frail people who feel a need for care, a need met by caregivers. Here we must always stand on two legs. We have to live in constructions, we have to examine what we have done with reference to constructions and then continually adjust the constructions. But they do indeed have to be adjusted, it must not be forgotten that it is not possible to live with constructions alone, but rather that they must be drawn from situations with internally diffuse significance. This is the core idea that I wanted to elaborate here: that the person-to-person encounter alone is not sufficient to give appropriate assistance to a person needing care; rather, this only works if one has at the same time a sensitive feeling for situations from which the singular as singular emerges by virtue of language. This need to sense situations and to differentiate them with utmost subtlety is exceptionally important in a primary situation of distress such as that of people in need of help or care; therefore, it must not be restricted to an I-Thou relationship, but rather, this I-Thou relationship must always be embedded into situations from which, as it were, the I and Thou can only be isolated by virtue of language, at least as a singular I and a singular Thou. Absolute identity and singularity must be distinguished. But now I do not want to go into that any further.1

References Schmitz, H (2014). Kurze Einführung in die Neue Phänomenologie [Brief introduction to New Phenomenology], 4th ed. Freiburg: Verlag Karl Alber. 1 Helpful explanations relevant to this text can be found in my book Kurze Einführung in die Neue Phänomenologie [Brief introduction to New Phenomenology], 4th ed. (2014, Freiburg: Verlag Karl Alber); for more detail see my book Ausgrabungen zum wirklichen Leben [Excavations on real life] (2016, Freiburg: Verlag Karl Alber).

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List of contributors, with key publications Prof. dr. Gernot Böhme Prof. dr. Roger Burggraeve Prof. dr. Maurice Hamington Dr. Klaartje Klaver Dr. med. and PhD Elin Martinsen Dr. Hanneke van der Meide Prof. dr. Per Nortvedt Prof. dr. Hermann Schmitz Dr. Linus Vanlaere Prof. Dr. Frans Vosman Prof. Dr. Bernhard Waldenfels Gernot Böhme, prof. dr., Institute for Practicing Philosophy, IPPh, Darmstadt, Germany. Three key publications: Böhme, G. (ed.). (2013). Pflegenotstand: der humane Rest. Bielefeld: Aisthesis Verlag. Böhme, G. (2014). Technics, Meditation, Atmospheres. Main Areas of Gernot Böhme’s Philosophy. In Czerniak, S. (Ed.), Dialogue and Universalism XXIV (4). Böhme, G., Engels-Schwarzpaul, A.-Chr. (Ed. and Trans.). (2017). Atmospheric Architectures. The Aesthetics of Felt Spaces. London: Bloomsbury.

Roger Burggraeve, Prof. dr., Professor emeritus Theological Ethics Catholic University Louvain, Belgium & Levinas Scholar. Three key publications:  Burggraeve, R. (2009). Proximity with the Other. A Multidimensional Ethic of Responsibility in Levinas. Bangalore: Dharmaram Publications. Burggraeve, R. (2016). An Ethics of Mercy. On the Way to Meaningful Living and Loving. Leuven/Paris/Bristol (CT): Peeters. Burggraeve, R. (2019). A Philosophical Postscript: Care Ethics in the Wake  of Emmanuel Levinas. In Vanlaere, L., Burggraeve, R., & Lategan, L., Vulnerable Responsibility. Small Vices for caregivers (Chapter 7, pp.  111-142). Bloemfontein (South Africa): Sun Press.

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Maurice Hamington, Professor of Philosophy, Portland State University Three key publications: Hamington, M. & Rosenow, C. (2019). Care Ethics and Poetry. Palgrave Macmillan. Hamington, M. (2017). Integrating Care Ethics and Design Thinking. The Journal of Business Ethics. doi:10.1007/s10551-017-3522-6 Hamington, M. (2004). Embodied Care: Jane Addams, Maurice  Merleau-Ponty and Feminist Ethics. Champaigin, IL: University of Illinois Press.

Dr. Klaartje Klaver, Researcher, Centre for Consultation and Expertise (www.cce.nl) Three key publications Klaver, K. & Baart, A. (2011). Attentive care in a hospital. Towards an empirical ethics of care. Medical Anthropology: A journal about health and culture 23 (2), 309-324. Klaver, K. & Baart, A. (2016). Managing socio-institutional enclosure. A grounded theory of caregivers’ attentiveness in hospital oncology care. European journal of oncology nursing 22, 95-102. Klaver, K. & Baart, A. (2016). How can attending physicians be more attentive? On being attentive versus producing attentiveness. Medicine, Healthcare and Philosophy: 19 (3), 351–359.

Dr. Elin Håkonsen Martinsen: Medical Doctor and Specialist in Child and Adolescent Psychiatry. PhD in Medical Ethics. Key Publications: Martinsen EH, Weimand BM, Pedersen R, et al. The silent world of young next of kin in mental healthcare. Nurs Ethics 2017. DOI: 10.1177/0969733017694498. Martinsen, EH. Care for nurses only? Medicine and the perceiving eye. Health Care Anal 2011; 19: 15-27. Martinsen, EH. Harm in the absence of care: Towards a medical ethics that cares. Nurs Ethics 2011; 18(2), 174-183.

Dr. Hanneke van der Meide: Postdoctoral Researcher Tilburg University, The Netherlands Key publications Meide, H. van der, Teunissen, T., Collard, P., Visse, M., & Visser, L. (2018). The mindful body. A phenomenology of the body with MS. Qualitative Health Research 28 (14), 2239–2249. Meide, H. van der, Gorp, D. van, Hiele, K. van der, & Visser, L. (2017). “Always looking for a new balance”: towards an understanding of what it takes to continue

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working while being diagnosed with relapsing-remitting Multiple Sclerosis. Disabil Rehabil 40 (21), 2545-2552. Meide, H. van der, Leget, C., & Olthuis, G. (2015). Participating in a world that is out of tune: shadowing an older hospital patient. Medicine, Health Care and Philosophy 18, 577-585.

Per Nortvedt. Professor emeritus, Dr. Political Science, Center for Medical Ethics, University of Oslo. Three Key Publications: Nortvedt, P. (2008). Sensibility and Clinical Understanding. Medicine, Health Care and Philosophy 11 (2), 209-219. Nortvedt, P., Skirbekk, H., & Hem, M. H. (2011). The Ethics of Care: Role Obligations and Moderate Partiality in Health Care. Nursing Ethics 18 (2), 192-200. Nortvedt, P. (2012). The Normativity of Clinical Health Care: Perspectives on Moral Realism. Journal of Medicine and Philosophy 37 (3), 277-294.

Hermann Schmitz, Professor of Philosophy, University of Kiel, Germany Three key publications: Schmitz, H. (2014). Kurze Einführung in die Neue Phänomenologie (4th ed.). Freiburg: Verlag Karl Alber. Schmitz, H. (2017). The Felt Body and Embodied Communication. In Feger, H., Landweer, H., Dikun, X., & Ge, W. (Eds.), Embodiment. Phenomenology East/West (Yearbook for Eastern and Western Philosophy) (Vol. 2, pp. 9-19). Berlin/Boston: De Gruyter. Schmitz, H. (2010). Emotions outside the box—the new phenomenology of feeling and corporeality (R. O. Müllan, J. Slaby, Trans.). Phenomenology and the cognitive sciences 10, 241-259. [Entseelung der Gefühle, in: Kerstin Andermann/Undine Eberlein (Hg.), Gefühle als Atmosphären. Neue Phänomenologie und philosophische Emotionsforschung (Deutsche Zeitschrift für Philosophie, Sonderheft 29), Berlin, 2011, p. 21-33.]

Linus L. Vanlaere, PhD, Professor Health Care ethics, VIVES University of Applied Sciences (Kortrijk & Bruges, Belgium); Research Volunteer at KU Leuven Three key publications: Vanlaere, L., Burggraeve, R., & Lategan, L. (2019). Vulnerable Responsibility. Small Vices for caregivers. Bloemfontein (South Africa): Sun Press. Baur, V., Van Nistelrooij, I., & Vanlaere, L. (2017). The sensible health care professional: a care ethical perspective on the role of caregivers in emotion-

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ally turbulent practices. 21 Medicine, Health Care and Philosophy 20 (4), 483493. Vanlaere, L., & Burggraeve, R. (2017). The quality of care: a care ethics approach. In Lategan, L. O. K. & Van Zyl, G. J. (Eds.), Healthcare ethics for healthcare Practitioners (pp. 43-52). Bloemfontein (South Africa): SUN MeDIA.

Frans Vosman, prof. dr., professor emeritus Ethics of care, University of Humanistic Studies, Utrecht, the Netherlands Three key publications: Vosman, F. J. H. (2018). The moral relevance of lived experience in complex hospital practices: a phenomenological approach. In van den Heuvel, S. C., Nullens, P., & Roothaan, A. (Eds.), Theological ethics and moral value phenomena. The experience of values (pp. 65-92). Abingdon, New York: Routledge. Vosman, F. J. H., Timmerman, A. B., & Baart, A. J. (2018). Digging into care practices: the confrontation of care ethics with qualitative empirical and theoretical developments in the Low Countries, 2007–17. International Journal of Care and Caring 2 (3), 405-423. doi: 10.1332/239788218X15321005652967 Vosman, F. J. H., Bakker, J., & Weenink, D. (2016). How to make sense of suffering in complex care practices? In Spaargaren, G., Weenink, D., & Lamers, M. (Eds.), Practice Theory and Research. Exploring the dynamics of social life (pp.  117-130). London and New York: Routledge.

Bernhard Waldenfels: Professor emeritus in Philosophy, Ruhr University Bochum, Germany Three key publications: Waldenfels, B. (2007). The Question of the Other. Hong Kong: The Chinese University Press / New York: SUNY Press. Waldenfels, B. (2011). Phenomenology of the Alien: Basic Concepts (T. Stähler, Trans.). Evanston, IL: Northwestern University Press. Waldenfels, B. (forthcoming). Registers of Responding (D. Goodwin, Trans.).

Ethics of Care

1. C. Leget, C. Gastmans, M. Verkerk (eds.), Care, Compassion and Recognition: An Ethical Discussion, 2011, IV-250 p. 2. A. van Heijst, Professional Loving Care. An Ethical View of the Healthcare Sector, 2011, VI-212 p. 3. G. Olthuis, H. Kohlen, J. Heier (eds.), Moral Boundaries Redrawn. The Significance of Joan Tronto’s Argument for Political Theory, Professional Ethics, and Care as Practice, 2014, IV-232 p. 4. I. van Nistelrooij, Sacrifice. A Care-Ethical Reappraisal of Sacrifice and Self-Sacrifice, 2015, X-302 p. 5. R.J. Lynch, Care: An Analysis, 2016, X-305 p. 6. S. Bourgault, E. Pulcini (eds.), Emotions and Care: Interdisciplinary Perspectives, 2018, VI-262 p. 7. F. Brugère, Care Ethics, 2019, The Introduction of Care as Political Category. With a Preface by Joan Tronto, 2019, VI-101 p. 8. F. Vosman, A. Baart, J. Hoffman, The Ethics of Care: The State of the Art, forthcoming.